RESUMO
At the front line of our medical system and population health, emergency medicine (EM) settings serve as a commonly perceived place for safety. Survivors of intimate partner violence (IPV) may present to the emergency department (ED) with injuries, illness, or specifically to seek help for IPV. In 2018, the U.S. Preventive Services Task Force (USPSTF) recommended screening women of reproductive age for IPV across all healthcare settings. Our objective was to examine the application of IPV interventions, resource allocation, and persistent barriers for screening within the EM setting following the USPSTF recommendation. This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). Our initial search of two major databases, PubMed and CINAHL, found 259 articles. After screening for inclusion and exclusion criteria, 15 articles met the full study criteria. Inconsistencies in screening women for IPV in EM are still prevalent. No study used the same validated IPV screening tool and four did not specify the tool. Significant barriers to screening included time constraints, patient acuity, language barriers, staff education, and inability to connect patients to resources. There is a need for more consistent IPV screening in the EM setting, which may include the development of a standardized, inclusive screening tool, as well as additional research and sharing of best practices. Advancement of IPV identification must go beyond a recommendation with greater awareness and education changes at all levels: personal, institutional, and policy.
RESUMO
BACKGROUND: Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. METHODS: In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. RESULTS: Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. CONCLUSIONS: Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.
RESUMO
INTRODUCTION: Cluster surveillance, identification, and containment are primary outbreak management techniques; however, adapting these for low- and middle-income countries is an ongoing challenge. We aimed to evaluate the utility of prehospital call center ambulance dispatch (CCAD) data for surveillance by examining the correlation between influenza-like illness (ILI)-related dispatch calls and COVID-19 cases. METHODS: We performed a retrospective analysis of state-level CCAD and COVID-19 data recorded between January 1 and April 30, 2020, in Telangana, India. The primary outcome was a time series correlation between ILI calls in CCAD and COVID-19 case counts. Secondarily, we looked for a year-to-year correlation of ILI calls in the same period over 2018, 2019, and 2020. RESULTS: On average, ILI calls comprised 12.9% (95% CI 11.7%-14.1%) of total daily calls in 2020, compared to 7.8% (95% CI 7.6%-8.0%) in 2018, and 7.7% (95% CI 7.5%-7.7%) in 2019. ILI call counts from 2018, 2019, and 2020 aligned closely until March 19, when 2020 ILI calls increased, representing 16% of all calls by March 23 and 27.5% by April 7. In contrast to the significant correlation observed between 2020 and previous years' January-February calls (2020 and 2019-Durbin-Watson test statistic [DW] = 0.749, p < 0.001; 2020 and 2018-DW = 1.232, p < 0.001), no correlation was observed for March-April calls (2020 and 2019-DW = 2.012, p = 0.476; 2020 and 2018-DW = 1.820, p = 0.208). In March-April 2020, the daily reported COVID-19 cases by time series significantly correlated with the ILI calls (DW = 0.977, p < 0.001). The ILI calls on a specific day significantly correlated with the COVID-19 cases reported 6 days prior and up to 14 days after (cross-correlation > 0.251, the 95% upper confidence limit). CONCLUSIONS: The statistically significant time series correlation between ILI calls and COVID-19 cases suggests prehospital CCAD can be part of early warning systems aiding outbreak cluster surveillance, identification, and containment.
Assuntos
COVID-19 , Call Centers , Influenza Humana , Humanos , Influenza Humana/epidemiologia , Estudos Retrospectivos , COVID-19/epidemiologia , AmbulânciasRESUMO
Background: Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness. Methods: We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory. Results: Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection. Conclusions: EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.
Assuntos
Serviços Médicos de Emergência , Adolescente , Criança , Mortalidade da Criança , Dispneia , Feminino , Humanos , Recém-Nascido , Pobreza , Estudos RetrospectivosRESUMO
BACKGROUND: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS. METHODS: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU. RESULTS: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable. CONCLUSION: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.
Assuntos
Estado de Consciência , Serviços Médicos de Emergência , Estudos Transversais , Escala de Coma de Glasgow , Humanos , Dor , TriagemRESUMO
BACKGROUND: Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees' use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course. METHODS: We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed. RESULTS: Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide. CONCLUSIONS: Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.
Assuntos
Medicina de Emergência , Estudantes de Medicina , Hospitais de Ensino , Humanos , Pesquisa Qualitativa , UgandaRESUMO
BACKGROUND: The determinants of coronavirus disease 2019 (COVID-19) disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterized relationships between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNAemia and disease severity, clinical deterioration, and specific EPCs. METHODS: We used quantitative and digital polymerase chain reaction (qPCR and dPCR) to quantify SARS-CoV-2 RNA from plasma in 191 patients presenting to the emergency department with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterized the role of RNAemia in predicting clinical severity and EPCs using elastic net regression. RESULTS: Of SARS-CoV-2-positive patients, 23.0% (44 of 191) had viral RNA detected in plasma by dPCR, compared with 1.4% (2 of 147) by qPCR. Most patients with serial measurements had undetectable RNAemia within 10 days of symptom onset, reached maximum clinical severity within 16 days, and symptom resolution within 33 days. Initially RNAemic patients were more likely to manifest severe disease (odds ratio, 6.72 [95% confidence interval, 2.45-19.79]), worsening of disease severity (2.43 [1.07-5.38]), and EPCs (2.81 [1.26-6.36]). RNA loads were correlated with maximum severity (râ =â 0.47 [95% confidence interval, .20-.67]). CONCLUSIONS: dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Because many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.
RESUMO
Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.
Assuntos
Comportamento de Busca de Ajuda , Violência por Parceiro Íntimo , Feminino , Humanos , Polícia , Prevalência , Sobreviventes , ViolênciaRESUMO
INTRODUCTION: Cryptococcus gattii (C. gatti) is a rare cause of meningitis in the United States. Outbreaks in new geographic distributions in the past few decades raise concern that climate change may be contributing to a broader distribution of this pathogen. We review a case of C. gattii in a 23-year-old woman in Northern California who was diagnosed via lumbar puncture after six weeks of headache, blurred vision, and tinnitus. CASE REPORT: A 23-year-old previously healthy young woman presented to the emergency department (ED) after multiple visits to primary care, other EDs, and neurologists, for several weeks of headache, nausea, tinnitus, and blurred vision. On examination the patient was found to have a cranial nerve VI palsy (impaired abduction of the left eye) and bilateral papilledema on exam. Lumbar puncture had a significantly elevated opening pressure. Cerebrospinal fluid studies were positive for C. gattii. The patient was treated with serial lumbar punctures, followed by lumbar drain, as well as amphotericin and flucytosine. The patient had improvement in headache and neurologic symptoms and was discharged to another facility that specializes in management of this disease to undergo further treatment with immunomodulators and steroids. CONCLUSION: Fungal meningitis is uncommon in the US, particularly among immunocompetent patients. Due to climate change, C. gattii may be a new pathogen to consider. This finding raises important questions to the medical community about the way global climate change affects day to day medical care now, and how it may change in the future.
RESUMO
Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic. Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals). Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80). Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.
RESUMO
BACKGROUND: Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India. METHODS: From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide). LESSONS LEARNED: During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials. CONCLUSION: These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.
RESUMO
OBJECTIVES: Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints (CCs) are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether CCs independently predict emergency unit patient outcomes. METHODS: Patient data collected in a Ugandan emergency unit between 2009 and 2018 were randomized into validation and derivation data sets. A recursive partitioning algorithm stratified CCs by 3-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, CCs were categorized as "high-risk" (>2× baseline mortality), "medium-risk" (between 2 and 0.5× baseline mortality), and "low-risk" (<0.5× baseline mortality). Risk categories were then included in a logistic regression model to determine if CCs independently predicted 3-day mortality. RESULTS: Overall, the derivation data set included 21,953 individuals with 7,313 in the validation data set. In total, 43 complaints were categorized, and 12 CCs were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk CCs significantly increased 3-day mortality odds ratio (OR = 2.39, 95% confidence interval [CI] = 1.95 to 2.93, p < 0.001) while low-risk CCs significantly decreased 3-day mortality odds (OR = 0.16, 95% CI = 0.09 to 0.29, p < 0.001). CONCLUSIONS: High-risk CCs were identified and found to predict increased 3-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.
Assuntos
Países em Desenvolvimento , Serviços Médicos de Emergência , Triagem , Adulto , Idoso , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Distribuição Aleatória , Estudos Retrospectivos , Sinais VitaisRESUMO
BACKGROUND: In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint. METHODS: Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality. RESULTS: A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days. CONCLUSIONS: This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.
Assuntos
Dispneia/mortalidade , Insuficiência Respiratória/mortalidade , Adolescente , Ambulâncias , Criança , Pré-Escolar , Estudos de Coortes , Demografia , Dispneia/fisiopatologia , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência/tendências , Feminino , Humanos , Índia/epidemiologia , Lactente , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Modelos Logísticos , Masculino , Prognóstico , Estudos Prospectivos , Insuficiência Respiratória/fisiopatologiaRESUMO
INTRODUCTION: Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India. METHODS: This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages. RESULTS: Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year. CONCLUSION: This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources.
Assuntos
Esgotamento Profissional/epidemiologia , Auxiliares de Emergência/psicologia , Tratamento de Emergência/psicologia , Adulto , Esgotamento Profissional/psicologia , Estudos Transversais , Auxiliares de Emergência/estatística & dados numéricos , Emoções , Feminino , Mão de Obra em Saúde/estatística & dados numéricos , Humanos , Índia/epidemiologia , Satisfação no Emprego , Masculino , Reorganização de Recursos Humanos/estatística & dados numéricos , Prevalência , Inquéritos e Questionários/estatística & dados numéricosRESUMO
Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication.
RESUMO
Established in 2011, the Global Emergency Medicine Academy (GEMA) aims "to improve the global delivery of emergency care through research, education, and mentorship." Global health remains early in its development as an academic track in emergency medicine, and there are only a small number of global emergency medicine academic faculty in most institutions. Consequently, GEMA focused its efforts at the Society for Academic Emergency Medicine (SAEM) Annual Meeting in 2019 on developing a diverse pool of global health academics and leaders in emergency medicine. Current and previous members of the GEMA Executive Committee convened to appraise and describe how current GEMA efforts situate within existing knowledge in the arenas of professional development and mentorship. The 2019 SAEM Annual Meeting unveiled the Global Emergency Medicine Roadmap, a joint venture between GEMA and the residents and medical students (RAMS) group. The roadmap guides medical students, residents, and fellows in the exploration of global emergency medicine and career development. GEMA's mentorship roundtable complemented this effort by providing a version of speed mentoring across several critical areas: work-life balance, identifying near-peer and long-distance mentoring opportunities, negotiating with your Chair, finding funding, networking, and teaching abroad. Finally, the GEMA-sponsored panel "Empowering Women through Emergency Care Development in LMICs" underscored the potential for empowering women through global emergency medicine development, including policy advocacy, inclusive research approaches, and mentorship and sponsorship. In summary, GEMA is committed to developing a diverse group of future global health leaders to guide the expansion of emergency medicine worldwide. Our work indicates critical future directions in global emergency medicine education and training including building innovative mentoring networks across institutions and countries. Further, we will continue to focus on growing faculty diversity, empowering underrepresented populations through emergency care development, and supporting rising global emergency medicine faculty in their pursuit of advancement and promotion.
RESUMO
Background: The determinants of COVID-19 disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterise the relationships between SARS-CoV-2 RNAaemia and disease severity, clinical deterioration, and specific EPCs. Methods: We used quantitative (qPCR) and digital (dPCR) PCR to quantify SARS-CoV-2 RNA from nasopharyngeal swabs and plasma in 191 patients presenting to the Emergency Department (ED) with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterised the role of RNAaemia in predicting clinical severity and EPCs using elastic net regression. Findings: 23·0% (44/191) of SARS-CoV-2 positive patients had viral RNA detected in plasma by dPCR, compared to 1·4% (2/147) by qPCR. Most patients with serial measurements had undetectable RNAaemia 10 days after onset of symptoms, but took 16 days to reach maximum severity, and 33 days for symptoms to resolve. Initially RNAaemic patients were more likely to manifest severe disease (OR 6·72 [95% CI, 2·45 - 19·79]), worsening of disease severity (OR 2·43 [95% CI, 1·07 - 5·38]), and EPCs (OR 2·81 [95% CI, 1·26 - 6·36]). RNA load correlated with maximum severity (r = 0·47 [95% CI, 0·20 - 0·67]). Interpretation: dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAaemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Since many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAaemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.
RESUMO
BACKGROUND: Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population. METHODS: We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality. RESULTS: We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N = 2088), of lower economic status (97%, N = 2805 used a government issued ration card) and were from rural or tribal areas (74%, N = 2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)). CONCLUSIONS: EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.
Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/normas , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Serviços Médicos de Emergência/normas , Feminino , Humanos , Índia/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pobreza , Estudos Prospectivos , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVES: The purpose of this study was twofold: (1) establish the prevalence of safety threats and workplace violence (WPV) experienced by emergency medical technicians (EMTs) in a low/middle-income country with a new prehospital care system, India and (2) understand which EMTs are at particularly high risk for these experiences. SETTING: EMTs from four Indian states (Gujarat, Karnataka, Tamil Nadu and Telangana) were eligible to participate during the study period from July through November 2017. METHODS: Cross-sectional survey study. PARTICIPANTS: 386 practicing EMTs from four Indian states. RESULTS: The overall prevalence of any WPV was 67.9% (95% CI 63.0% to 72.5%). The prevalence of physical assault was 58% (95% CI 52.5% to 63.4%) and verbal assault was 59.8% (95% CI 54.5% to 65%). Of physical assault victims, 21.7% were injured and 30.2% sought medical attention after the incident. Further, 57.3% (n=216) of respondents reported they were 'somewhat worried' and 28.4% (n=107) reported they were 'very worried' about their safety at work. CONCLUSION: WPV and safety fears were found to be common among EMTs in India. Focused initiatives to counter WPV in countries developing prehospital care systems are necessary to build a healthy and sustainable prehospital healthcare workforce.
Assuntos
Auxiliares de Emergência , Violência no Trabalho/estatística & dados numéricos , Adulto , Estudos Transversais , Feminino , Humanos , Índia/epidemiologia , Modelos Logísticos , Masculino , Prevalência , Inquéritos e Questionários , Violência no Trabalho/prevenção & controle , Violência no Trabalho/psicologia , Adulto JovemRESUMO
A large proportion of the total global burden of disease is caused by emergency medical conditions. Emergency care research is essential to improving emergency medicine but this research can raise some distinctive ethical challenges, especially with regard to (1) standard of care and risk-benefit assessment; (2) blurring of the roles of clinician and researcher; (3) enrolment of populations with intersecting vulnerabilities; (4) fair participant selection; (5) quality of consent; and (6) community engagement. Despite the importance of research to improve emergency care in low-income and middle-income countries (LMICs) and the widely acknowledged ethical challenges, very little has been written on the ethics of emergency care research in LMICs. This paper examines the ethical and regulatory challenges to conducting emergency care research with human participants in LMICs. We outline key challenges, present potential solutions or frameworks for addressing these challenges, and identify gaps. Despite the ethical and regulatory challenges, conducting high-quality, ethical emergency care research in LMICs is possible and it is essential for global health.