Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings.

BACKGROUND: A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner. METHODS: We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000. RESULTS: The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics. CONCLUSIONS: While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study.

INTRODUCTION: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

Changing patterns in the burden of paediatric injuries during the COVID-19 pandemic: a study in Mozambique's central hospitals.

INTRODUCTION: There is a substantial body of knowledge on the effects of the COVID-19 pandemic on injuries showing frequent but inconsistent reductions in both volume and pattern. Yet, studies specifically addressing children are less common, not least from low- and middle-income countries. This study investigated whether changes in the pattern and outcome of paediatric injury admissions to Mozambique's four regional referral hospitals during 2020. METHODS: Clinical charts of paediatric patients presenting to the targeted hospitals with acute injuries were reviewed using a set of child, injury, and outcome characteristics during each of two consecutive restriction periods in 2020 using as a comparator the same periods in 2019, the year before the pandemic. Differences between 2020 and 2019 proportions for any characteristic were examined using the t-test (significance level 0.05). RESULTS: During both restriction periods, compared with the previous year, reductions in the number of injuries were noticed in nearly all aspects investigated, albeit more remarkably during the first restriction period, in particular, greater proportions of injuries in the home setting and from burns (7.2% and 11.5% respectively) and a reduced one of discharged patients (by 2.5%). CONCLUSION: During the restrictions implemented to contend the pandemic in Mozambique in 2020, although each restriction period saw a drop in the volume of injury admissions at central hospitals, the pattern of child, injury and outcome characteristics did not change much, except for an excess of home and burn injuries in the first, more restrictive period. Whether this reflects the nature of the restrictions only or, rather, other mechanisms that came into play, individual or health systems related, remains to be determined.

External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study.

BACKGROUND: Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa. METHODS: An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days. RESULTS: Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage. CONCLUSION: No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.

Changes in trauma-related emergency medical services during the COVID-19 lockdown in the Western Cape, South Africa.

BACKGROUND: To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS). METHODS: We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test. RESULTS: During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied. CONCLUSION: This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions.

The costs of delivering emergency care at regional referral hospitals in Uganda: a micro-costing study.

BACKGROUND: Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions. METHODS: A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions. RESULTS: Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p < 0.05) with treatments for paediatric diarrhoea having the lowest median cost of all conditions (p < 0.05). CONCLUSION: This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.

Multi-method versus single method appraisal of clinical quality indicators for the emergency medical services.

BACKGROUND: Quality Indicator (QI) appraisal protocol is a novel methodology that combines multiple appraisal methods to comprehensively assess the 'appropriateness' of QIs for a particular healthcare setting. However, they remain inadequately explored compared to the single appraisal method approach. OBJECTIVES: To describe and test a multi-method QI appraisal protocol versus the single method approach, against a series of QIs previously identified as potentially relevant to the prehospital emergency care setting. METHODS: An appraisal protocol was developed consisting of two categorical-based appraisal methods, combined with the qualitative analysis of the discussion generated during the consensus application of each method. The output of the protocol was assessed and compared with the application and output of each method. Inter-rater reliability (IRR) of each particular method was evaluated prior to group consensus rating. Variation in the number of non-valid QIs and the proportion of non-valid QIs identified between each method and the protocol were compared and assessed. RESULTS: There was mixed IRR of the individual methods. There was similarly low-to-moderate correlation of the results obtained between the particular methods (Spearman's rank correlation = 0.42, P < 0.001). From a series of 104 QIs, 11 non-valid QIs were identified that were shared between the individual methods. A further 19 non-valid QIs were identified and not shared by each method, highlighting the benefits of a multi-method approach. The outcomes were additionally evident in the group discussion analysis, which in and of itself added further input that would not have otherwise been captured by the individual methods alone. CONCLUSION: The utilization of a multi-method appraisal protocol offers multiple benefits, when compared to the single appraisal approach, and can provide the confidence that the outcomes of the appraisal will ensure a strong foundation on which the QI framework can be successfully implemented.

Strengthening emergency care knowledge and skills in Uganda and Tanzania with the WHO-ICRC Basic Emergency Care Course.

BACKGROUND: There is a pressing need for emergency care (EC) training in low-resource settings. We assessed the feasibility and acceptability of training frontline healthcare providers in emergency care with the World Health Organization (WHO)-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) Course using a training-of-trainers (ToT) model with local providers. METHODS: Quasiexperimental pretest and post-test study of an educational intervention at four first-level district hospitals in Tanzania and Uganda conducted in March and April of 2017. A 2-day ToT course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC Course, taught by the newly trained trainers, at two hospitals in each country. Both prior to and immediately following each training, participants took assessments on EC knowledge and rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants was collected and summarised. RESULTS: Fifty-nine participants completed the four BEC Courses. All participants were current healthcare workers at the selected hospitals. An additional 10 participants completed a ToT course. EC knowledge scores were significantly higher for participants immediately following the training compared with their scores just prior to the training when assessed across all study sites (Z=6.23, p<0.001). Across all study sites, mean EC confidence ratings increased by 0.74 points on a 4-point Likert scale (95% CI 0.63 to 0.84, p<0.001). Main qualitative feedback included: positive reception of the sessions, especially hands-on skills; request for additional BEC trainings; request for obstetric topics; and need for more allotted training time. CONCLUSIONS: Implementation of the WHO-ICRC BEC Course by locally trained providers was feasible, acceptable and well received at four sites in East Africa. Participation in the training course was associated with a significant increase in EC knowledge and confidence at all four study sites. The BEC is a low-cost intervention that can improve EC knowledge and skill confidence across provider cadres.

Epidemiology and outcomes from severe hypoglycemia in Kuwait: a prospective cohort study.

BACKGROUND: The objective of this study was to describe the epidemiology of severe hypoglycaemia in Kuwait, aiming to provide a preliminary background to update the current guidelines and improve patient management. METHOD: This was a prospective analysis of severe hypoglycaemia cases retrieved from emergency medical services (EMS) archived data between 1 January and 30 June 2020. The severe hypoglycaemia cases were then sub-grouped based on EMS personal initial management and compared in terms of scene time, transportation rate, complications and outcomes. The primary outcomes were GCS within 10-30 min and normal random blood glucose (RBS) within 10-30 min. RESULTS: A total of 167 cases met the inclusion criteria. The incidence of severe hypoglycaemia in the national EMS was 11 per 100,000. Intramuscular glucagon was used on scene in 89% of the hypoglycaemic events. Most of the severe hypoglycaemia patients regained normal GCS on scene (76.5%). When we compared the two scene management strategies for severe hypoglycaemia cases, parenteral glucose administration prolonged the on-scene time (P = .002) but was associated with more favourable scene outcomes than intramuscular glucagon, with normal GCS within 10-30 min (P = .05) and normal RBS within 10-30 min (P = .006). CONCLUSION: Severe hypoglycaemia is not uncommon during EMS calls. Appropriate management by EMS personals is fruitful, resulting in favourable scene outcomes and reducing the hospital transportation rate. More research should be invested in improving and structuring the prehospital management of severe hypoglycaemia. One goal is to clarify the superiority of parenteral glucose over intramuscular glucagon in the prehospital setting.

Using the South African Triage Scale for prehospital triage: a qualitative study.

BACKGROUND: Triage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied. METHODS: In this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes. RESULTS: 15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients. CONCLUSIONS: Overall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training.

Validity and reliability of the South African Triage Scale in prehospital providers.

BACKGROUND: The South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage. METHODS: This is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components - triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers' responses. RESULTS: A total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators. CONCLUSION: This is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed. TRIAL REGISTRATION: Not applicable.

Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review.

OBJECTIVE: To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. METHODS: Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. RESULTS: Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. CONCLUSION: We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.

Prioritizing the Care of Critically Ill Children in South Africa: How Does SCREEN Perform Against Other Triage Tools?

OBJECTIVE: Childhood mortality remains unacceptably high. In low-resource settings, children with critical illness often present for care. Current triage strategies are time consuming and require trained health care workers. To address this limitation, our team developed a simple subjective tool, SCREEN (Sick Children Require Emergency Evaluation Now), which is easy to administer, to identify critically ill children. This article presents the development of the SCREEN program and evaluates its performance when compared with other commonly implemented triage tools in low-resource settings. METHODS: We measured the sensitivity and specificity of SCREEN, to identify critically ill children, compared with 4 other previously validated triage tools: the Integrated Management of Childhood Illnesses, the Pediatric Early Warning, the Pediatric South African Triage Scale, and the World Health Organization Emergency Triage Treatment Tool. FINDINGS: SCREEN has high sensitivity (100%-98.73%; P < 0.001) and specificity (64.41%-50.71%; P < 0.001) when compared with other validated triage tools. CONCLUSIONS: The SCREEN tool may offer a simple and effective method to identify critically ill children in low-resource environments.

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.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise.

BACKGROUND: More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions. METHODS: The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings. RESULTS: The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs. CONCLUSIONS: Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

m-Health for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers.

Introduction:The rapid adoption of smartphones, especially in low- and middle-income countries, has opened up novel ways to deliver health care, including diagnosis and management of burns. This study was conducted to measure acceptability and to identify factors that influence health care provider's attitudes toward m-health technology for emergency care of burn patients.Methods:An extended version of the technology acceptance model (TAM) was used to assess the acceptability toward using m-health for burns. A questionnaire was distributed to health professionals at four hospitals in Dar Es Salaam, Tanzania. The questionnaire was based on several validated instruments and has previously been adopted for the sub-Saharan context. It measured constructs, including acceptability, usefulness, ease of use, social influences, and voluntariness. Univariate analysis was used to test our proposed hypotheses, and structural equation modeling was used to test the extended version of TAM.Results:In our proposed test-model based on TAM, we found a significant relationship between compatibility-usefulness and usefulness-attitudes. The univariate analysis further revealed some differences between subgroups. Almost all health professionals in our sample already use smartphones for work purposes and were positive about using smartphones for burn consultations. Despite participants perceiving the application to be easy to use, they suggested that training and ongoing support should be available. Barriers mentioned include access to wireless internet and access to hospital-provided smartphones.

Cross-sectional evaluation of emergency care capacity at public hospitals in Zambia.

OBJECTIVES: The last decade has seen rapid expansion of emergency care systems across Africa, although they remain underdeveloped. In Zambia, the Ministry of Health has taken interest in improving the situation and data are needed to appropriately guide system strengthening efforts. The Emergency Care Assessment Tool (ECAT) provides a context-specific means of measuring capacity of healthcare facilities in low- and middle-income countries. We evaluated Zambian public hospitals using the ECAT to inform resource-effective improvements to the nation's healthcare system. METHODS: The ECAT was administered to the lead clinician in the emergency unit at 23 randomly sampled public hospitals across seven of Zambia's 10 provinces in March 2016. Data were collected regarding hospitals' perceived abilities to perform a number of predefined signal functions - life-saving procedures that encompass the need for both skills and resources. Signal functions (36 for intermediate facilities, 51 for advanced) related to six sentinel conditions that represent a large burden of morbidity and mortality from emergencies. We report the proportion of procedures that each level of hospital was capable of, along with barriers to delivery of care. RESULTS: Across all hospitals, most of the level-appropriate emergency care procedures could be performed. Intermediate level (district) hospitals were able to perform 75% (95% CI 73.2 to 76.8) of signal functions for the six conditions. Among advanced level hospitals, provincial hospitals were able to perform 68.6% (67.4% to 69.7%) and central hospitals 96.1% (95% CI 93.5 to 98.7) Main failures in delivery of care were attributed to a lack of healthcare worker training and availability of consumable resources, such as medicines or supplies. CONCLUSION: Zambian public hospitals have reasonable capacity to care for acutely ill and injured patients; however, there is a need for increased training and improved supply chains.

Towards developing a consensus assessment framework for global emergency medicine fellowships.

BACKGROUND: The number of Global Emergency Medicine (GEM) Fellowship training programs are increasing worldwide. Despite the increasing number of GEM fellowships, there is not an agreed upon approach for assessment of GEM trainees. MAIN BODY: In order to study the lack of standardized assessment in GEM fellowship training, a working group was established between the International EM Fellowship Consortium (IEMFC) and the International Federation for Emergency Medicine (IFEM). A needs assessment survey of IEMFC members and a review were undertaken to identify assessment tools currently in use by GEM fellowship programs; what relevant frameworks exist; and common elements used by programs with a wide diversity of emphases. A consensus framework was developed through iterative working group discussions. Thirty-two of 40 GEM fellowships responded (80% response). There is variability in the use and format of formal assessment between programs. Thirty programs reported training GEM fellows in the last 3 years (94%). Eighteen (56%) reported only informal assessments of trainees. Twenty-seven (84%) reported regular meetings for assessment of trainees. Eleven (34%) reported use of a structured assessment of any sort for GEM fellows and, of these, only 2 (18%) used validated instruments modified from general EM residency assessment tools. Only 3 (27%) programs reported incorporation of formal written feedback from partners in other countries. Using these results along with a review of the available assessment tools in GEM the working group developed a set of principles to guide GEM fellowship assessments along with a sample assessment for use by GEM fellowship programs seeking to create their own customized assessments. CONCLUSION: There are currently no widely used assessment frameworks for GEM fellowship training. The working group made recommendations for developing standardized assessments aligned with competencies defined by the programs, that characterize goals and objectives of training, and document progress of trainees towards achieving those goals. Frameworks used should include perspectives of multiple stakeholders including partners in other countries where trainees conduct field work. Future work may evaluate the usability, validity and reliability of assessment frameworks in GEM fellowship training.

Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review.

BACKGROUND: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. METHODS: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. RESULTS: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. CONCLUSIONS: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

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.