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The delivery of emergency care is an effective strategy to reduce the global burden of disease. Emergency care cross cuts traditional disease-focused disciplines to manage a wide range of the acute illnesses and injuries that contribute substantially to death and disability, particularly in low- and middle-income countries. While the universal health coverage (UHC) movement is gaining support, and human rights and health systems are integral to UCH, few concrete discussions on the human right to emergency care have been taken place to date. Furthermore, no rights-based approach to developing emergency care systems has been proposed. In this article, we explore key components of the right to health (that is, availability, accessibility, acceptability and quality of health facilities, goods and services) as they relate to emergency care systems. We propose the use of a rights-based framework for the fulfilment of core obligations of the right to health and the progressive realization of emergency care in all countries.
La prestation de soins d'urgence constitue une stratégie efficace pour réduire la charge mondiale de morbidité. Les soins d'urgence recoupent les disciplines traditionnelles centrées sur les maladies pour prendre en charge de nombreuses blessures et affections aiguës qui contribuent sensiblement aux décès et aux handicaps, en particulier dans les pays à revenu faible et intermédiaire. Alors que le mouvement pour la couverture sanitaire universelle prend de l'ampleur et que les droits de l'homme et les systèmes de santé en font partie intégrante, peu de discussions concrètes sur le droit à des soins d'urgence ont eu lieu à ce jour. En outre, aucune démarche fondée sur les droits et visant à développer des systèmes de soins d'urgence n'a été proposée. Dans cet article, nous nous intéressons aux composantes clés du droit à la santé (à savoir la disponibilité, l'accessibilité, l'acceptabilité et la qualité des établissements, des produits et des services de soins) pour ce qui est des systèmes de soins d'urgence. Nous proposons d'utiliser un cadre fondé sur les droits pour l'exécution des obligations essentielles du droit à la santé et la mise en place progressive de soins d'urgence dans tous les pays.
La prestación de atención de emergencia es una estrategia eficaz para reducir la carga mundial de morbilidad. La atención de emergencia trasciende las disciplinas tradicionales centradas en las enfermedades para tratar una amplia gama de enfermedades y lesiones agudas que contribuyen sustancialmente a la muerte y la discapacidad, en particular en los países de ingresos bajos y medianos. Si bien el movimiento de la cobertura sanitaria universal (CSU) está ganando apoyo, y los derechos humanos y los sistemas de salud son parte integral de la CSU, hasta la fecha se han llevado a cabo pocas discusiones concretas sobre el derecho humano a la atención de emergencia. Además, no se ha propuesto un enfoque basado en los derechos para desarrollar sistemas de atención de emergencia. En este artículo exploramos los componentes clave del derecho a la salud (es decir, disponibilidad, accesibilidad, aceptabilidad y calidad de las instalaciones, bienes y servicios sanitarios) en relación con los sistemas de atención de emergencia. Proponemos el uso de un marco basado en los derechos para el cumplimiento de las obligaciones básicas del derecho a la salud y la realización progresiva de la atención de emergencia en todos los países.
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Servicios Médicos de Urgencia , Accesibilidad a los Servicios de Salud , Derecho a la Salud , Cobertura Universal del Seguro de Salud , Países en Desarrollo , Salud Global , Derechos Humanos , Humanos , Calidad de la Atención de Salud , Naciones UnidasRESUMEN
OBJECTIVES: Essential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications. The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury. METHODS: We undertook a multistep consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final inperson consensus process. RESULTS: The final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML, but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (eg, district hospitals) and an additional 78 for advanced facilities (eg, tertiary centres). CONCLUSION: The 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation and will be a useful tool for practical expansion of emergency care delivery in Africa.
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Medicamentos Esenciales/clasificación , Servicios Médicos de Urgencia/métodos , África , Consenso , Países en Desarrollo/estadística & datos numéricos , Humanos , Pautas de la Práctica en Medicina/tendencias , Encuestas y Cuestionarios , Organización Mundial de la Salud/organización & administraciónRESUMEN
BACKGROUND: Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care. OBJECTIVES: We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems. ELIGIBILITY CRITERIA: English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described. SOURCE OF EVIDENCE: PubMed, Embase, Web of Science, CINAHL and the grey literature. CHARTING METHODS: A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF). RESULTS: A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%). CONCLUSIONS: Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.
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Países en Desarrollo , Servicios Médicos de Urgencia , Humanos , Calidad de la Atención de Salud , Acomodación OcularRESUMEN
Introduction: Climate change is a global public health emergency with implications for access to care and emergency care service disruptions. The African continent is particularly vulnerable to climate-related extreme weather events due to an already overburdened health system, lack of early warning signs, poverty, inadequate infrastructure, and variable adaptive capacity. Emergency care services are not only utilized during these events but also threatened by these hazards. Considering that the effects of climate change are expected to increase in intensity and prevalence, it is increasingly important for emergency care to prepare to respond to the changes in presentation and demand. The aim of this study was to perform a scoping review of the available literature on the relationship between climate change and emergency care on the African continent. Methods: A scoping review was completed using five databases: Pubmed, Web of Science, GreenFILE, Africa Wide Information, and Google Scholar. A 'grey' literature search was done to identify key reports and references from included articles. Two independent reviewers screened articles and a third reviewer decided conflicts. A total of 1,382 individual articles were initially screened with 17 meeting full text review. A total of six articles were included in the final analysis. Data from four countries were represented including Uganda, Ghana, Tanzania, and Nigeria. Results: Analysis of the six articles yielded three key themes that were identified: climate-related health impacts that contribute to surges in demand and resource utilization, opportunities for health sector engagement, and solutions to improve emergency preparedness. Authors used the outcomes of the review to propose 10 recommendations for decision-makers and leaders. DXDiscussion: Incorporating these key recommendations at the local and national level could help improve preparedness and adaptation measures in highly vulnerable, populated areas on the African continent.
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OBJECTIVES: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS. DESIGN: A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. PARTICIPANT: The initial search strategy yielded 15 232 articles; 124 met inclusion criteria. RESULTS: Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries. CONCLUSIONS: This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic.
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COVID-19 , Triaje , Humanos , Estudios Prospectivos , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND: In 2013, the Zambian Ministry of Health identified action priorities for strengthening their emergency care system; one of these priorities was emergency care training for healthcare providers. To rapidly train the existing cadre of frontline providers, trainings were implemented in multiple provinces using the World Health Organization's Basic Emergency Care (BEC) course. The BEC course is open-access and emphasizes a practical syndrome-based approach to critical emergency conditions. This paper describes the first reported larger scale educational intervention of the BEC course in 7 provinces of Zambia. METHODS: Course delivery occurred at seven Zambian hospitals selected by the Ministry of Health over a 1 year period. Participant emergency care knowledge was assessed pre- and post-course with a 25-question multiple choice exam. Participant confidence levels related to emergency care provision and emergency care skills were assessed pre- and post-course using a Likert scale survey. RESULTS: Overall, 210 participants were trained at 7 sites. Participants demonstrated significant improvements in their multiple-choice exam scores; the overall pre-course mean was 61.47, and the post-course mean was 79.87 (p < 0.0001). Self-reported confidence in the care of ill and injured adults and children increased after taking the course, and participants generally agreed that the BEC course was highly valuable and applicable to local needs. CONCLUSION: Implementation of the WHO's BEC course at seven hospitals throughout Zambia led to improvement in the participants' emergency care knowledge and confidence levels at all sites. The BEC course has the potential to be implemented in a nationwide initiative but would require allocation of significant human and physical resources. Additional work evaluating patient outcomes and long-term participant educational outcomes is needed.
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Effective identification and prognostication of severe COVID-19 patients presenting to healthcare facilities are essential to reducing morbidity and mortality. Low- and middle-income country (LMIC) facilities often suffer from restrictions in availability of human resources, laboratory testing, medications, and imaging during routine functioning, and such shortages may worsen during times of surge. Low- and middle-income country healthcare providers will need contextually appropriate tools to identify and triage potential COVID-19 patients. We report on a series of LMIC-appropriate recommendations and suggestions for screening and triage of COVID-19 patients in LMICs, based on a pragmatic, experience-based appraisal of existing literature. We recommend that all patients be screened upon first contact with the healthcare system using a locally approved questionnaire to identify individuals who have suspected or confirmed COVID-19. We suggest that primary screening tools used to identify individuals who have suspected or confirmed COVID-19 include a broad range of signs and symptoms based on standard case definitions of COVID-19 disease. We recommend that screening include endemic febrile illness per routine protocols upon presentation to a healthcare facility. We recommend that, following screening and implementation of appropriate universal source control measures, suspected COVID-19 patients be triaged with a triage tool appropriate for the setting. We recommend a standardized severity score based on the WHO COVID-19 disease definitions be assigned to all suspected and confirmed COVID-19 patients before their disposition from the emergency unit. We suggest against using diagnostic imaging to improve triage of reverse transcriptase (RT)-PCR-confirmed COVID-19 patients, unless a patient has worsening respiratory status. We suggest against the use of point-of-care lung ultrasound to improve triage of RT-PCR-confirmed COVID-19 patients. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients who are RT-PCR negative but have moderate to severe symptoms and are suspected of a false-negative RT-PCR with high risk of disease progression. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients with moderate or severe clinical features who are without access to RT-PCR testing for SARS-CoV-2.
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Prueba de COVID-19/métodos , COVID-19/diagnóstico , Países en Desarrollo , Tamizaje Masivo/métodos , Guías de Práctica Clínica como Asunto , Triaje/métodos , COVID-19/epidemiología , COVID-19/prevención & control , Prueba de COVID-19/normas , Servicio de Urgencia en Hospital , Humanos , Tamizaje Masivo/organización & administración , Tamizaje Masivo/normas , Triaje/organización & administraciónRESUMEN
This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.
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Cuidados Críticos , Atención a la Salud , Enfermedad Crítica/terapia , Instituciones de Salud , Humanos , PobrezaRESUMEN
Cases of COVID-19 are rising quickly on the African continent. A critical element of any health system response to such a surge of active cases is the existence of functional emergency care systems. Yet, these systems are markedly underdeveloped in African countries. This short letter reviews the key role emergency medicine plays in epidemic disease response and actions that ministries of health can take now to shore up gaps in emergency care capacity to avoid needless death and suffering of COVID-19 patients.
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COVID-19/terapia , Servicios Médicos de Urgencia/métodos , Resultado del Tratamiento , África/epidemiología , COVID-19/epidemiología , Servicios Médicos de Urgencia/normas , Servicios Médicos de Urgencia/tendencias , HumanosRESUMEN
INTRODUCTION: Depression is characterized by a persistent state of low mood and aversion to activity affecting a person's thoughts, behavior, feelings and sense of well-being. It has been reported in Orthopaedic trauma patients. Depression is likely to interfere in an individual's ability to sustain a long duration rehabilitation programme leading to poor function and delayed return to a productive lifestyle. The objective of this study was to identify the prevalence and identify factors associated with depression in indoor Orthopaedic trauma patients. METHODS: This prospective cohort study was conducted on 190 adult Orthopaedic trauma patients enrolled on a randomly selected day of a week subject to written informed consent. Patients with conditions that may preclude assessment of the mental status were excluded from the study. Age, sex, duration since injury, Injury Severity Score (ISS), type of surgery, marital status, insurance coverage, level of education, socioeconomic status, familial support, substance abuse. Hospital anxiety and depression scale (HADS) score and pain score (visual analogue scale) were recorded as soon as the patient was stabilized. Bivariate analyses and Logistic regression were used to identify factors associated with a HADS score of ≥8. RESULTS: Mean age was 33.8 years. One hundred fifty-one (79.47%) patients were males and thirty-nine patients were females (21.53%). A HADS score ≥8 was present in 42.63% enrolled cases. On logistic regression a higher pain score, nuclear family, and female sex were found to be significantly associated with HADS ≥8. CONCLUSION: Depression is common in indoor Orthopaedic trauma patients. HADS may be used to screen patients for depression and refer patients to a psychiatrist for a definitive diagnosis and management.
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INTRODUCTION: Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20-30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. OBJECTIVES: Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. METHODS: A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. KEY RECOMMENDATIONS: Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.
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Since the adoption of the Sustainable Development Goals in 2015, innovation in global healthcare delivery has been recognized as a vital avenue for strengthening health systems and overcoming present implementation bottlenecks. In the recent rapid development of the science of global health-care delivery, emergency care-a critical element of the health system-has been widely overlooked. Emergency care plays a vital role in the health system through providing immediately responsive care and serving as one of the main entry points for those with symptomatic disease. We present a new perspective on emergency care's role in the health system within the context of global health-care delivery, and argue that, if properly integrated, emergency care has the potential to add significant value across the healthcare continuum. Capitalizing on emergency care as a shared delivery infrastructure presents opportunities to increase efficiency not only in treatment of time-sensitive conditions, but also for secondary prevention through its capacity to promote early disease detection and enhance coordination of care. We propose an integrated emergency care delivery value chain, demonstrating emergency care's critical position as a point of access to the greater health system and its key connections to longitudinal care delivery, which remain under-developed in low- and middle-income country health systems. As emergency care systems are created within emerging and established health systems, this role can be more effectively leveraged by policy makers and healthcare leaders globally to promote progress towards the Sustainable Development Goals.
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Prestación Integrada de Atención de Salud/métodos , Servicios Médicos de Urgencia/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Países en Desarrollo , Servicios Médicos de Urgencia/provisión & distribución , Salud Global , HumanosRESUMEN
Emergency care and the emergency care system encompass an array of time-sensitive interventions to address acute illness and injury. Research has begun to clarify the enormous economic burden of acute disease, particularly in low-income and middle-income countries, but little is known about the cost-effectiveness of emergency care interventions and the performance of health financing mechanisms to protect populations against catastrophic health expenditures. We summarise existing knowledge on the economic value of emergency care in low resource settings, including interventions indicated to be highly cost-effective, linkages between emergency care financing and universal health coverage, and priority areas for future research.
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Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.
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Facility-based emergency care delivery in low-income and middle- income countries is expanding rapidly, particularly in Africa. Unfortunately, these efforts rarely include measurement of the quality or the impact of care provided, which is essential for improvement of care provision. Our aim was to determine context-appropriate quality indicators that will allow uniform and objective data collection to enhance emergency care delivery throughout Africa. We undertook a multiphase expert consensus process to identify, rank and refine quality indicators. A comprehensive review of the literature identified existing indicators; those associated with a substantial burden of disease in Africa were categorised and presented to consensus conference delegates. Participants selected indicators based on inclusion criteria and priority clinical conditions. The indicators were then presented to a group of expert clinicians via on-line survey; all meeting agreements were refined in-person by a separate panel and ranked according to validity, feasibility and value. The consensus working group selected seven conditions addressing nearly 75% of mortality in the African region to prioritise during indicator development, and the final product at the end of the multiphase study was a list of 76 indicators. This comprehensive process produced a robust set of quality indicators for emergency care that are appropriate for use in the African setting. The adaptation of a standardised set of indicators will enhance the quality of care provided and allow for comparison of system strengthening efforts and resource distribution.
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Healthcare facilities in low-income and middle-income countries lack an objective measurement tool to assess emergency care capacity. The African Federation for Emergency Medicine developed the Emergency Care Assessment Tool (ECAT) to fulfil this function. The ECAT assesses the provision of key medical interventions (signal functions) that emergency units (EUs) should be able to perform to adequately treat six common, life-threatening conditions (sentinel conditions). We describe the piloting and refinement of the ECAT, to improve usability and context-appropriateness. We undertook iterative, multisite refinement of the ECAT. After pilot testing at a South African referral hospital, subsequent studies occurred at district, regional and central facilities across four countries representing the major regions of Africa: Cameroon, Uganda, Egypt and Botswana. At each site, the tool was administered to three participants: one senior physician, one senior nurse and one other clinical provider. Feedback informed refinements of the ECAT, and an updated tool was used in the next-studied country. Iteratively implementing refined versions of the tool in various contexts across Africa resulted in a final ECAT that uses signal functions, categorised by sentinel conditions and evaluated against discrete barriers to emergency care service delivery, to assess EUs. It also allowed for refinement of administration and data analysis processes. The ECAT has a total of 71 items. Advanced facilities are expected to perform all 71 signal functions, while intermediate facilities should be able to perform 53. The ECAT is the first tool to provide a standardised method for assessing facility-based emergency care in the African context. It identifies where in the maturation process a hospital or system is and what gaps exist in delivery of care, so that a comprehensive roadmap for development can be established. Although validity and feasibility testing have now occurred, reliability studies must be conducted prior to amplification across the region.