Fall injuries in Sub-Saharan Africa: analysis of prospective injury registry from 23 health facilities in Malawi and Tanzania.

BACKGROUND: Low-and middle-income countries account for over 80% of fall-related fatalities globally. However there is little emphasis on the issue and limited high quality data to understand the burden, and to inform preventive and management strategies. We characterise the burden of fall injuries in Malawi and Tanzania. METHODS: This multi-centre prospective descriptive study utilized trauma registry data from 10 hospitals in Malawi and 13 hospitals in Tanzania. The study included twelve months of data in Tanzania (October 2019 to September 2020), and eighteen months of data from Malawi (September 2018 to March 2020). We describe patient demographics, the causes, location, and nature of injuries, timing of arrival to hospital, and final disposition. Regression analyses were performed to determine risk factors for serious injuries. RESULTS: There were 93,178 trauma patients in the registries of both countries, of which 44,609 (47.9%) had fall related complaints. Fall injuries accounted for 55.3% and 17.4% of all trauma cases in Malawi and Tanzania respectively. Overall the median age was 16 years (Interquartile range (IQR) 8-31 years), and 62.8% were male. Most fall injuries (69.9%) occurred at home, were unintentional (98.1%), and were due to a ground level fall (74.9%). Nearly half of patients (47.9%) arrived at a facility using public transport, with median arrival time of 10 h (IQR 8-13 h) from initial injury. Extremities (87.0%) were the most commonly injured region, followed by head and neck (4.4%). Overall 3275 (7.4%) patients had potentially serious injuries. Age > 60 years was associated with two times odds of having serious injuries than those < 5 years, and those sustaining injury at work (adjusted Odds Ratio (aOR) 1.95 95% CI; 1.56-2.43) or recreational areas (aOR 3.47 95% CI; 2.93-4.10) had higher odds of serious injuries compared to those injured at home. CONCLUSIONS: In these facilities in Sub-Saharan Africa, fall injuries accounted for a substantial fraction of all injuries. While most common in younger males, those aged 5-13 and over 60 years were more likely to have serious injuries. Most falls occurred at home, but serious injuries were more likely to occur at recreational and work areas. Future efforts should focus on preventive strategies to mitigate these injuries.

Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania.

BACKGROUND: Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness. METHODOLOGY: This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients. Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively. RESULTS: We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9-60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1-5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4-4.0) and 1.8(95% CI 1.1-2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9-1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021). CONCLUSION: The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Predictors and outcome of cardiac arrest in paediatric patients presenting to emergency medicine department of tertiary hospitals in Tanzania.

BACKGROUND: The survival of children who suffer cardiac arrest is poor. This study aimed to determine the predictors and outcome of cardiac arrest in paediatric patients presenting to an emergency department of a tertiary hospital in Tanzania. METHODOLOGY: This was a prospective cohort study of paediatric patients > 1 month to ≤ 14 years presenting to Emergency Medicine Department of Muhimbili National Hospital (EMD) in Tanzania from September 2019 to January 2020 and triaged as Emergency and Priority. We enrolled consecutive patients during study periods where patients' demographic and clinical presentation, emergency interventions and outcome were recorded. Logistic regression analysis was performed to identify the predictors of cardiac arrest. RESULTS: We enrolled 481 patients, 294 (61.1%) were males, and the median age was 2 years [IQR 1-5 years]. Among studied patients, 38 (7.9%) developed cardiac arrest in the EMD, of whom 84.2% were ≤ 5 years. Referred patients were over-represented among those who had an arrest (84.2%). The majority 33 (86.8%) of those who developed cardiac arrest died. Compromised circulation on primary survey (OR 5.9 (95% CI 2.1-16.6)), bradycardia for age on arrival (OR 20.0 (CI 1.6-249.3)), hyperkalemia (OR 8.2 (95% CI 1.4-47.7)), elevated lactate levels > 2 mmol/L (OR 5.2 (95% CI 1.4-19.7)), oxygen therapy requirement (OR 5.9 (95% CI 1.3-26.1)) and intubation within the EMD (OR 4.8 (95% CI 1.3-17.6)) were independent predictors of cardiac arrest. CONCLUSION: Thirty-eight children developed cardiac arrest in the EMD, with a very high mortality. Those who arrested were more likely to present with signs of hypoxia, shock and acidosis, which suggest they were at later stage in their illness. Outcomes can be improved by strengthening the pre-referral care and providing timely critical management to prevent cardiac arrest.

Aetiologies and outcomes of patients with abdominal pain presenting to an emergency department of a tertiary hospital in Tanzania: a prospective cohort study.

BACKGROUND: Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania. METHODS: This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality. RESULTS: Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001). CONCLUSION: Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.

Emergency medicine registrar training in Africa: overview of programmes, faculty and sustainability.

BACKGROUND: The specialty of emergency medicine (EM) is new in most African countries, where emergency medicine registrar (residency) programmes (EMRPs) are at different stages of evolution and little is known about the programmes. Identifying and describing these EMRPs will facilitate planning for sustainability, collaborative efforts and curriculum development for existing and future programmes. Our objective was to identify and provide an overview of existing EMRPs in Africa and their applicant requirements, faculty characteristics and plans for sustainability. METHODS: We conducted a descriptive cross-sectional survey of Africa's EMRPs between January and December 2017, identifying programmes through an online search supplemented by discussions with African EM leaders. Leaders of all identified African EMRPs were invited to participate. Data were collected prospectively using a structured survey and are summarised with descriptive statistics. RESULTS: We identified 15 programmes in 12 countries and received survey responses from 11 programmes in 10 countries. Eight of the responding EMRPs began in 2010 or later. Only 36% of the EMRPs offer a 3-year programme. Women make up an average of 33% of faculty. Only 40% of EMRPs require faculty to be EM specialists. In smaller samples that reported the relevant data, 67% (4/6) of EMRPs have EM specialists who trained in that EMRP programme making up more than half of their faculty; 57% of Africa's 288 EMRP graduates to date are men; and an average of 39% of EMRP graduates stay on as faculty for 78% (7/9) of EMRPs. CONCLUSION: EMRPs currently produce most of their own EM faculty. Almost equal proportions of men and women have graduated from a predominantly >3-year training programme. Graduates have a variety of opportunities in academia and private practice. Future assessments may wish to focus on the evolution of these programme' curricula, faculty composition and graduates' career options.

Trauma care and capture rate of variables of World Health Organisation data set for injury at regional hospitals in Tanzania: first steps to a national trauma registry.

BACKGROUND: In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set. METHODS: This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. RESULTS: During the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. CONCLUSIONS: In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.

Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania. METHODS: This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality. RESULTS: During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32-64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3-4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7-29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8-22.8). CONCLUSIONS: In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Feasibility and yield of HIV screening among adult trauma patients presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: The World Health Organization and Tanzanian National Guidelines for HIV and AIDS management, recommends provider initiated testing and counseling for HIV at any point of health care contact. In Tanzania, over 45% of people living with HIV are unaware of their HIV positive status. We determine the feasibility and yield of HIV screening among otherwise healthy adult trauma patients presenting to the first full-capacity Emergency Department in Tanzania. METHODS: This was a prospective cohort study of consecutive adult trauma patients presenting to Emergency Medicine Department at Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, from March 2017 to September 2017. Eligible patients provided informed consent, pre and post-test counseling was done. Structured case report forms were completed, documenting demographics, acceptance of testing, results and readiness to receive results. Outcomes were the proportion of patients accepting testing, proportion of positive tests, readiness of the patient to receive the results, and proportion of patients who had an HIV test ordered as part of care. RESULTS: We screened 2848 trauma patients, and enrolled 326 (11.5%) eligible patients. Median age was 33 (IQR 25-42 years), and 248 (76.0%) of participants were male. Of those enrolled, 250 (76.7%) patients accepted testing for HIV, and among them 247 (98.8%) were ready to receive their test results. Of those tested, 14 (5.6%) were found to be HIV positive and 12 were ready to receive results. Two months post hospital discharge 6 (50%), of those who were informed of positive results had visited Care and Treatment Clinics (CTC) for HIV treatment. Three additional patients had not yet attended and three could not be reached. The treating ED physician tested none of the enrolled patients for HIV as part of their regular treatment. CONCLUSIONS: In our cohort of adult trauma patients presenting to ED, routine HIV screening for unrelated reason, was feasible and acceptable. The yield is sufficient to warrant an on-going program and superior to having physicians choose which patients to test. Future studies should focus on factors affecting the linkage to CTC among HIV positive patients identified at the ED.

Undernourished children presenting to an urban emergency department of a tertiary hospital in Tanzania: a prospective descriptive study.

BACKGROUND: Childhood undernutrition causes significant morbidity and mortality in low- and middle-income countries (LMICs). In Tanzania, the in-hospital prevalence of undernutrition in children under five years of age is approximated to be 30% with a case fatality rate of 8.8%. In Tanzania, the burden of undernourished children under five years of age presenting to emergency departments (EDs) and their outcomes are unknown. This study describes the clinical profiles and outcomes of this population presenting to the emergency department of Muhimbili National Hospital (ED-MNH), a large, urban hospital in Dar es Salaam, Tanzania. METHODS: This was a prospective descriptive study of children aged 1-59 months presenting to the ED-MNH over eight weeks in July and August 2016. Enrolment occurred through consecutive sampling. Children less than minus one standard deviation below World Health Organization mean values for Weight for Height/Length, Height for Age, or Weight for Age were recruited. Structured questionnaires were used to document primary outcomes of patient demographics and clinical presentations, and secondary outcomes of 24-h and 30-day mortality. Data was summarised using descriptive statistics and relative risks (RR). RESULTS: A total of 449 children were screened, of whom 34.1% (n = 153) met criteria for undernutrition and 95.4% (n = 146) of those children were enrolled. The majority of these children, 56.2% (n = 82), were male and the median age was 19 months (IQR 10-31 months). They presented most frequently with fever 24.7% (n = 36) and cough 24.0% (n = 35). Only 6.7% (n = 9) were diagnosed with acute undernutrition by ED-MNH physicians. Mortality at 24 h and 30 days were 2.9% (n = 4) and 12.3% (n = 18) respectively. A decreased level of consciousness with Glasgow Coma Scale below fifteen on arrival to the ED and tachycardia from initial vital signs were found to be associated with a statistically significant increased risk of death in undernourished children, with mortality rates of 16.1% (n = 23), and 24.6% (n = 35), respectively. CONCLUSIONS: In an urban ED of a tertiary referral hospital in Tanzania, undernutrition remains under-recognized and is associated with a high rate of in-hospital mortality.

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.

Emergency medicine residency training in Africa: overview of curriculum.

BACKGROUND: Emergency Medicine (EM) is a rapidly developing specialty in Africa with several emergency medicine residency-training programs (EMRPs) established across the continent over the past decade. Despite rapid proliferation of the specialty, little is known about emergency care curriculum structure and content. We provide an overview of Africa's EMRPs. METHODS: This was a descriptive cross-sectional survey conducted of EMRPs in Africa between January 2017 and December 2017. Data were prospectively collected using a structured survey that was developed and administered through online data capture software, REDCap (Version 7.2.2, Vanderbilt, Nashville, TN, USA). Survey questions focused on curriculum structure and design, including clinical rotations, didactics, research, and evaluation. Data are summarized with descriptive statistics. RESULTS: The survey was sent to the leadership of 15 EMRPs in 12 different African countries and 11 (73%) responded. Five (46%) of the responding programs were started by local non-EM trained faculty, two (18%) were started by international partners, and the remainder by a combination of local non-EM faculty and international partners. Overall, Seven (64%) of the countries offer a 4-year EMRP. In General, 40% of curriculums are influenced the contents developed by African Federation for Emergency Medicine. All programs offer resident led-didactics, with a median of 12 h (Interquartile range 9-6 h) per month. All EMRPs have a mandatory research requirement. All EMRPs offer clinical rotations in the ED, Paediatrics, and Obstetrics and Gynaecology, while only 2 programs offer rotations in radiology and neonatal intensive care units. Only 46% of EMRPs have in-ED clinical supervision by specialist. CONCLUSION: The EMRPs in Africa were started by non-EM trained local faculty alone or collaboration with international partners. The curriculum offers most exposure to ED, and less exposure in radiology and neonatal intensive care. Residents are highly involved in leading didactics and less than half of the programs have in-ED specialist supervision of patient care.

Respiratory compromise in children presenting to an urban emergency department of a tertiary hospital in Tanzania: a descriptive cohort study.

BACKGROUND: Respiratory compromise is the leading cause of cardiac arrest and death among paediatric patients. Emergency medicine is a new field in low-income countries (LICs); the presentation, treatment and outcomes of paediatric patients with respiratory compromise is not well studied. We describe the clinical epidemiology, management and outcomes of paediatric patients with respiratory compromise presenting to the first full-capacity Emergency Department in Tanzania. METHODS: This was a prospective cohort study of paediatric patients (< 18 years) with respiratory compromise (respiratory distress, respiratory failure or respiratory arrest) presenting to the Emergency Medicine Department of Muhimibili National Hospital (EMD-MNH) in Dar es Salaam, from July-November 2017. A standardized case report form was used to record demographics, presenting clinical characteristics, management and outcomes. Primary outcomes were hospital mortality and secondary outcomes were EMD mortality, 24-h mortality, incidence of cardiac arrest in the EMD, length of stay, ICU admission, and risk factors for mortality. RESULTS: We enrolled 165 children; their median age was 12 months [IQR: 4-36 months], and 90 (54.4%) were male. At presentation 92 (55.8%) children were in respiratory failure. Oxygen therapy was initiated for 143 (86.7%) children, among which 21 (14.7%) were intubated. The most common aetiologies were pneumonia followed by congenital heart disease and sepsis. The majority 147 (89.1%) of children were admitted to the hospital, with 20 (12%) going to ICU. Four (2%) children were discharged from EMD and 14 (8.5%) died in the EMD. In the EMD, 18 children developed cardiac arrest, with two surviving to hospital discharge. Overall 51 (30.9%) children died; 84% of deaths were in children under five years. Risk of mortality was increased in children presenting with decreased consciousness (RR = 2.2 (1.4-3.4)), hypoxia RR = 2.6 (1.6-4.4)) or bradypnoea (RR = 3.9 (2.9-5.0)), and those who received CPR (RR = 3.7 (2.7-5.2)) and intubation (RR = 3.1 (2.1-4.5)). CONCLUSIONS: In this EMD of a LICs, respiratory compromise in children carries high mortality, with children of young age being the most vulnerable. Many children arrived in respiratory failure and few children received ICU care. Outcomes can be improved by earlier recognition to prevent cardiac arrest, and more intensive treatment, including ICU and assisted ventilation.

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.

The prevalence of alcohol and illicit drug use among injured patients presenting to the emergency department of a national hospital in Tanzania: a prospective cohort study.

BACKGROUND: Alcohol and illicit drugs have been found to be major contributing factors leading to severe injuries in a variety of settings. In Tanzania, the use of these substances among injured patients has not been studied. We investigated the prevalence of positive tests for alcohol and illicit drug use among injured patients presenting to the emergency medicine department (ED) of Muhimbili National Hospital (MNH). METHODS: This was a prospective cohort study of a consecutive sample of patients > 18 years of age presenting to the ED-MNH with injury related complaints in October and November 2015. A structured data sheet was used to record demographic information, mechanism of injury, clinical presentation, alcohol and illicit drug test results, and ED disposition. Alcohol levels and illicit drug use were tested by breathalyser device or swab stick alcohol test and multidrug urine panel, respectively. Patients were followed up for 24 h and 30 days using medical chart reviews and phone calls. Descriptive statistics and relative risk were used to describe the results. RESULTS: We screened 1011 patients and we enrolled all 143 (14.1%) patients who met inclusion criteria. 123 (86.0%) were male, the median age was 30 years (IQR: 23-36 years). The most frequent mechanism of injury was road traffic accidents (84.6%). 67/143 (46.9%) patients tested positive for alcohol and 44/122 (36.1%) patients tested positive for drugs. 29 (26.1%) tested positive for alcohol and drugs. The most frequently detected illicit drug was marijuana in 30/122 (24.5%) injured patients. 23/53 (43.4%) patients with positive alcohol testing self-reported alcohol use. 3/25 patients with positive illicit drug tests who were able to provide self-reports, self-reported drug use. At 30-day followup, 43 (64.2%) injured patients who tested positive for alcohol had undergone major surgery, 6 (9.0%) had died, and 36 (53.7%) had not yet returned to their baseline. CONCLUSIONS: The prevalence of alcohol and illicit drugs is very high in patients presenting to the ED-MNH with injury. Further studies are needed to generalise the results in Tanzania. Public health initiatives to decrease drinking and/or illicit drug use and driving should be implemented.

Profile and outcome of patients with emergency complications of renal failure presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Renal failure carries high mortality even in high-resource countries. Little attention has been paid to renal failure patients presenting acutely in emergency care settings in low-to-middle income countries (LMIC). Our aim was to describe the profile, management strategies and outcome of renal failure patients presenting with indications for emergent dialysis to an urban Emergency Department (ED) in a tertiary public hospital in Tanzania. METHODS: This was a prospective cohort study of consecutive patients (age ≥ 15 yrs) presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2017 to February 2018. All patients with renal failure and complications requiring acute dialysis were included. A structured data collection sheet was used to gather demographics, clinical presentation, management strategies and outcomes. Data were summarized with descriptive statistics. Logistic regressions were performed to determine factors associated with receiving dialysis and with mortality. RESULTS: We enrolled 146 patients, median age was 49 years (IQR 32-66 years), and 110 (75.3%) were male. Shortness of breath 67 (45.9%) and reduced urine output 58 (39.7%) were the most common presenting complaints. The most common complications were hyperkalemia 77 (53%), uremic encephalopathy 66 (45%) and pulmonary edema 54 (37%). All patients were hospitalized, and 61 (42%) received dialysis. Overall mortality was 39% (57 patients); the mortality in non-dialysed patients was 53% vs. 20% (p < 0.0005) in those receiving dialysis. 54% of patients with health insurance were dialyzed, compared to 39% who paid out of pocket (adjusted OR = 0.3, 95%CI: 0.1-0.9). Patients (≥55 years) were less likely to be dialysed (adjusted OR = 0.2 [0.1-0.9]). Independent predictors of mortality were vomiting (OR = 6.2, 95%CI: 1.8-22.2), oliguria (OR = 3.4, 95%CI: 1.2-9.5), pulmonary edema (OR = 4.6, 95%CI: 1.6-14.3), creatinine level > 1200umol/L (OR = 5.0 95%CI: 1.4-18.2), and not receiving dialysis (OR = 8.0, CI: 2.7-23.5). Female sex had a lower risk of dying (OR = 0.13, CI: 0.03-0.5). CONCLUSIONS: In this ED in LIC, acute complications of renal failure created a need for ED stabilization and emergent dialysis. Overall in-hospital mortality was high; significantly higher in undialysed patients. Future studies in LICs should focus on identification of categories of patients that will do well with conservative therapy.

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. METHODS: This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. RESULTS: We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. CONCLUSION: In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study.

BACKGROUND: Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. METHODS: This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. RESULTS: We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. CONCLUSION: This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.

Ketamine procedural sedation in the emergency department of an urban tertiary hospital in Dar es Salaam, Tanzania.

STUDY OBJECTIVE: We describe ketamine procedural sedations and associated adverse events in low-acuity and high-acuity patients in a resource-limited ED. METHODS: This was a prospective observational study of ketamine procedural sedations at the Emergency Medical Department at the Muhimbili National Hospital in Dar es Salaam, Tanzania. We observed consecutive procedural sedations and recorded patient demographics, medications, vital signs, pulse oximetry, capnography and a priori defined adverse events (using standard definitions in emergency medicine sedation guidelines). All treatment decisions were at the discretion of the treating providers who were blinded to study measurements to simulate usual care. Data collection was unblinded if predefined safety parameters were met. For all significant adverse and unblinding events, ketamine causality was determined via review protocol. Additionally, providers and patients were assessed for sedation satisfaction. RESULTS: We observed 54 children (median 3 years, range 11 days-15 years) and 45 adults (median 33 years, range 18-79 years). The most common indications for ketamine were burn management in children (55.6%) and orthopaedic procedures in adults (68.9%). Minor adverse events included nausea/vomiting (12%), recovery excitation (11%) and one case of transient hypertension. There were nine (9%) patients who had decreased saturation readings (SpO2 ≤92%). There were three deaths, all in severely injured patients. After review protocol, none of the desaturations or patient deaths were thought to be caused by ketamine. No patient experienced ketamine-related laryngospasm, apnoea or permanent complications. Overall, ketamine was well tolerated and resulted in high patient and provider satisfaction. CONCLUSION: In this series of ketamine sedations in an urban, resource-limited ED, there were no serious adverse events attributable to ketamine.

Trauma burden in Tanzania: a one-day survey of all district and regional public hospitals.

BACKGROUND: Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies. METHODS: This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported. RESULTS: A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22-35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas. CONCLUSIONS: Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

The test characteristics of physician clinical gestalt for determining the presence and severity of anaemia in patients seen at the emergency department of a tertiary referral hospital in Tanzania.

OBJECTIVES: To evaluate the test characteristics of clinical gestalt for detecting the presence and severity of anaemia in emergency department patients at a tertiary referral hospital in Tanzania. METHODS: This prospective study enrolled a convenience sample of emergency department patients who had a complete blood count ordered by the treating physician in the course of their clinical care. Physicians recorded their impression of the presence and severity of anaemia before viewing the laboratory results. To assess interobserver agreement, a second physician provided their blinded gestalt impression of the patient's haemoglobin level. RESULTS: We enrolled 216 patients and complete data were available for 210 patients (97%), 59% male, median age 30 years. The range of measured haemoglobin values was 1.5-15.4 g/dL. The physicians rated anaemia mild or absent in 74 (35%), moderate in 72 (34%) and severe in 64 patients (30%). These estimates were significantly concordant with the laboratory haemoglobin measurements (Kendall's τ b=0.63, 95% CI 0.57 to 0.69, p<0.0001). The test characteristics of physician gestalt estimates for severe anaemia were: sensitivity 64% (95% CI 53% to 74%), specificity 91% (95% CI 85% to 96%), positive likelihood ratio of 7.4 (95% CI 4.2 to 13.3) and negative likelihood ratio of 0.40 (0.3 to 0.5). The weighted Cohen's κ for interobserver agreement between physicians on the gestalt estimate of the degree of anaemia was 0.87 (95% CI 0.76 to 0.98). CONCLUSION: Physicians' estimates of the severity of anaemia were significantly concordant with laboratory haemoglobin measurements. Sensitivity of the gestalt estimate for severe anaemia was moderate. Interobserver agreement was 'almost perfect'.