Essential medicines for emergency care in Africa.

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.

Community-based perceptions of emergency care in Zambian communities lacking formalised emergency medicine systems.

BACKGROUND: In Zambia, an increasing burden of acute illness and injury emphasised the necessity of strengthening the national emergency care system. OBJECTIVE: The objective of this study was to identify critical interventions necessary to improve the Zambian emergency care system by determining the current pattern of emergency care delivery as experienced by members of the community, identifying the barriers faced when trying to access emergency care and gathering community-generated solutions to improve emergency care in their setting. METHODS: We used a qualitative research methodology to conduct focus groups with community members and healthcare providers in three Zambian provinces. Twenty-one community focus groups with 183 total participants were conducted overall, split equally between the provinces. An additional six focus groups were conducted with Zambian healthcare providers. Data were coded, aggregated and analysed using the content analysis approach. RESULTS: Community members in Zambia experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Community-identified and provider-identified barriers to emergency care included transportation, healthcare provider deficiencies, lack of community knowledge, the national referral system and police protocols. CONCLUSIONS: Creating community education initiatives, strengthening the formal prehospital emergency care system, implementing triage in healthcare facilities and training healthcare providers in emergency care were community-identified and provider-identified solutions for improving access to emergency care.

Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.

A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.

Application of the World Health Organization's Basic Emergency Care course in Zambia.

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.

Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review.

Background: Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings. Objective: To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships. Methods: An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted. Findings: Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding. Conclusions: Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.

Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa.

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.

Preparing Emergency Physicians for Acute Disaster Response: A Review of Current Training Opportunities in the US.

Study Objective This study aimed to review available disaster training options for health care providers, and to provide specific recommendations for developing and delivering a disaster-response-training program for non-disaster-trained emergency physicians, residents, and trainees prior to acute deployment. METHODS: A comprehensive review of the peer-reviewed and grey literature of the existing training options for health care providers was conducted to provide specific recommendations. RESULTS: A comprehensive search of the Pubmed, Embase, Web of Science, Scopus, and Cochrane databases was performed to identify publications related to courses for disaster preparedness and response training for health care professionals. This search revealed 7,681 unique titles, of which 53 articles were included in the full review. A total of 384 courses were found through the grey literature search, and many of these were available online for no charge and could be completed in less than six hours. The majority of courses focused on management and disaster planning; few focused on clinical care and acute response. CONCLUSION: There is need for a course that is targeted toward emergency physicians and trainees without formal disaster training. This course should be available online and should utilize a mix of educational modalities, including lectures, scenarios, and virtual simulations. An ideal course should focus on disaster preparedness, and the clinical and non-clinical aspects of response, with a focus on an all-hazards approach, including both terrorism-related and environmental disasters. Hansoti B , Kellogg DS , Aberle SJ , Broccoli MC , Feden J , French A , Little CM , Moore B , Sabato J Jr. , Sheets T , Weinberg R , Elmes P , Kang C . Preparing emergency physicians for acute disaster response: a review of current training opportunities in the US. Prehosp Disaster Med. 2016;31(6):643-647.

Perceptions of emergency care in Kenyan communities lacking access to formalised emergency medical systems: a qualitative study.

OBJECTIVES: We undertook this study in Kenya to understand the community's emergency care needs and barriers they face when trying to access care, and to seek community members' thoughts regarding high impact solutions to expand access to essential emergency services. DESIGN: We used a qualitative research methodology to conduct 59 focus groups with 528 total Kenyan community member participants. Data were coded, aggregated and analysed using the content analysis approach. SETTING: Participants were uniformly selected from all eight of the historical Kenyan provinces (Central, Coast, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley and Western), with equal rural and urban community representation. RESULTS: Socioeconomic and cultural factors play a major role both in seeking and reaching emergency care. Community members in Kenya experience a wide range of medical emergencies, and seem to understand their time-critical nature. They rely on one another for assistance in the face of substantial barriers to care-a lack of: system structure, resources, transportation, trained healthcare providers and initial care at the scene. CONCLUSIONS: Access to emergency care in Kenya can be improved by encouraging recognition and initial treatment of emergent illness in the community, strengthening the pre-hospital care system, improving emergency care delivery at health facilities and creating new policies at a national level. These community-generated solutions likely have a wider applicability in the region.