White Paper on Early Critical Care Services in Low Resource Settings.

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.

Emergency department management of traumatic brain injuries: A resource tiered review.

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.

Developing emergency care systems: a human rights-based approach.

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.

Advancing research on the economic value of emergency care.

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.

Evaluating emergency care capacity in Africa: an iterative, multicountry refinement of the Emergency Care Assessment Tool.

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.