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

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

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

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

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

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

Trauma care and capture rate of variables of World Health Organisation data set for injury at regional hospitals in Tanzania: first steps to a national trauma registry.

BACKGROUND: In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set. METHODS: This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. RESULTS: During the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. CONCLUSIONS: In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.

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

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

Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study.

BACKGROUND: Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. METHODS: This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. RESULTS: We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. CONCLUSION: This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.

The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage.

INTRODUCTION: Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. METHODS: Retrospective database review of the Trauma Audit and Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014. Patients were defined as Priority One if they received one or more LSIs from a previously defined list. Only patients with complete physiological data were included. Patients were categorised by the MPTT and existing triage tools using first recorded hospital physiology. Performance characteristics were evaluated using sensitivity, specificity and area under receiver operating characteristic (AUROC). RESULTS: During the study period, 218 985 adult patients were included in the TARN database. 127 233 (58.1%) had complete data: 55.6% male, aged 61.4 (IQR 43.1-80.0) years, Injury Severity Score 9 (IQR 9-16), 96.5% suffered blunt trauma and 24 791 (19.5%) were Priority One. The MPTT (sensitivity 57.6%, specificity 71.5%) outperformed all existing triage methods with a 44.7% absolute reduction in undertriage compared with existing UK civilian methods. AUROC comparison supported the use of the MPTT over other tools (P<0.001.) CONCLUSION: Within a civilian trauma registry population, the MPTT demonstrates improved performance at predicting need for LSI, with the lowest rates of undertriage and an appropriate level of overtriage. We suggest the MPTT be considered as an alternative to existing triage tools.

Trauma burden in Tanzania: a one-day survey of all district and regional public hospitals.

BACKGROUND: Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies. METHODS: This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported. RESULTS: A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22-35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas. CONCLUSIONS: Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

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.

Applying the lessons of maternal mortality reduction to global emergency health.

Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions.

Au cours des dernières décennies, la santé maternelle a figuré en bonne place dans les priorités de la communauté internationale et cela s'est traduit par une baisse considérable de la mortalité maternelle au niveau mondial. Or, même si la morbidité et la mortalité liées aux urgences médicales et chirurgicales sont bien plus élevées comparativement à celles associées aux pathologies maternelles, les efforts menés au niveau mondial pour améliorer les systèmes de soins d'urgence dans leur intégralité attirent beaucoup moins d'attention. Une application réfléchie et spécifique des concepts employés dans l'effort de réduction de la mortalité maternelle pourrait entraîner des améliorations notables au sein des services de santé d'urgence au niveau mondial. Le modèle dit « des trois retards ¼, conçu pour la mortalité maternelle, peut être transposé à la prestation des soins d'urgence. L'adaptation des cadres d'évaluation pour y inclure des critères-sentinelles évocateurs des cas d'urgence vitale pourraient permettre une surveillance efficace des centres d'urgences et la conception de politiques complémentaires. Les futurs efforts consacrés aux systèmes de soins d'urgence au niveau mondial pourraient également bénéficier de l'intégration de stratégies pour la planification et l'évaluation d'interventions à fort impact.

A lo largo de las últimas décadas, la salud materna ha sido un foco importante de la comunidad internacional y esto ha llevado a una disminución considerable de la mortalidad materna a nivel mundial. Aunque, en comparación con las enfermedades de la madre, las emergencias médicas y quirúrgicas son una causa mucho más importante de morbilidad y mortalidad, se ha puesto menos atención en los esfuerzos mundiales para mejorar los sistemas integrales de emergencia. La aplicación profunda y específica de los conceptos utilizados en el intento de disminuir la mortalidad materna puede llevar a mejoras importantes de los servicios sanitarios de emergencia mundiales. El denominado modelo de tres retrasos que se desarrolló para la mortalidad materna se puede adaptar a la prestación de servicios de emergencia. La adaptación de los marcos de evaluación para incluir condiciones centinela de emergencia podría permitir una supervisión efectiva de las instalaciones de emergencia y la elaboración de políticas adicionales. Los esfuerzos futuros en la sanidad de emergencia mundial podrían beneficiarse de la incorporación de estrategias para la planificación y evaluación de intervenciones de gran impacto.

Emergency care in 59 low- and middle-income countries: a systematic review.

OBJECTIVE: To conduct a systematic review of emergency care in low- and middle-income countries (LMICs). METHODS: We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards. FINDINGS: We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2-5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3-8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5-6.3%). The median number of patients was 30 000 per year (IQR: 10 296-60 000), most of whom were young (median age: 35 years; IQR: 6.9-41.0) and male (median: 55.7%; IQR: 50.0-59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. CONCLUSION: Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

Evaluating the construct of triage acuity against a set of reference vignettes developed via modified Delphi method.

OBJECTIVE: To evaluate the construct of triage acuity as measured by the South African Triage Scale (SATS) against a set of reference vignettes. METHODS: A modified Delphi method was used to develop a set of reference vignettes. Delphi participants completed a 2-round consensus-building process, and independently assigned triage acuity ratings to 100 written vignettes unaware of the ratings given by others. Triage acuity ratings were summarised for all vignettes, and only those that reached 80% consensus during round 2 were included in the reference set. Triage ratings for the reference vignettes given by two independent experts using the SATS were compared with the ratings given by the international Delphi panel. Measures of sensitivity, specificity, associated percentages for over-triage/under-triage were used to evaluate the construct of triage acuity (as measured by the SATS) by examining the association between the ratings by the two experts and the international panel. RESULTS: On completion of the Delphi process, 42 of the 100 vignettes reached 80% consensus on their acuity rating and made up the reference set. On average, over all acuity levels, sensitivity was 74% (CI 64% to 82%), specificity 92% (CI 87% to 94%), under-triage occurred 14% (CI 8% to 23%) and over-triage 12% (CI 8% to 23%) of the time. CONCLUSIONS: The results of this study provide an alternative to evaluating triage scales against the construct of acuity as measured with the SATS. This method of using 80% consensus vignettes may, however, systematically bias the validity estimate towards better performance.

The value of the difference between ED and prehospital vital signs in predicting outcome in trauma.

INTRODUCTION: Traditional vital signs are seen as an important part of trauma assessment, despite their poor predictive value in this regard. OBJECTIVE: This study evaluated whether the difference between systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and shock index (SI) taken in the emergency department (ED) and prehospital can predict 48 h mortality postadmission following trauma. METHODS: Retrospective cohort was obtained from the Trauma Audit and Research Network. Subjects were excluded if head or spinal injuries, prehospital intubation or CPR were present. Main outcome was 48 h mortality. The difference (delta, Δ) between ED and prehospital values were used as study variables (ie, ΔSI=SI-ED minus SI-prehospital). Accuracy was assessed using area under receiver operator characteristic curve (AUROC). AUROC coordinates were used to identify 95% specificity cut points and described further using sensitivity and likelihood ratios (LRs). RESULTS: Significant AUROC statistics were revealed for ΔSBP (0.57) and ΔRR (0.56) for the full sample, ΔSBP (0.62) and ΔSI (0.65) for moderate, and ΔRR (0.6) for severe injury. Best LRs were 3.4 and 2.4 for ΔRR and ΔSI, respectively, but sensitivities were low (<=26%). Cut point values for ΔSBP, ΔRR and ΔSI were 37 mm Hg, 8 breaths/min and 0.2, respectively. DISCUSSION: ΔSBP and ΔRR performed best overall, but ΔSI performed best in the moderate injury group, suggesting earlier identification with ΔSI. Use of Δ values result in good rule-in of 48 h mortality and may supplement trauma treatment decisions.

Patient Preferences for Out-of-Hospital Cardiac Arrest Care in South Africa: A Discrete Choice Experiment.

OBJECTIVE: This study examined the trade-offs low-resource setting community members were willing to make in regard to out-of-hospital cardiac arrest care using a discrete choice experiment survey. METHODS: We administered a discrete choice experiment survey to a sample of community members 18 years or older across South Africa between April and May 2022. Participants were presented with 18 paired choice tasks comprised of 5 attributes (distance to closest adequate facility, provider of care, response time, chances of survival, and transport cost) and a range of 3 to 5 levels. We used mixed logit models to evaluate respondents' preferences for selected attributes. RESULTS: Analyses were based on 2228 responses and 40 104 choice tasks. Patients valued care with the shortest response time, delivered by the highest qualified individuals, which placed them within the shortest distance of an adequate facility, gave them the highest chance of survival, and costed the least. In addition, patients preferred care delivered by their family members over care delivered by the lay public. The highest mean willingness-to-pay for increased survival is 11 699 South African rand (ZAR), followed by distance to health facility (8108 ZAR), and response time (5678 ZAR), and the lowest for increasing specialization of provider (1287 ZAR). CONCLUSIONS: In low-resource settings, it may align with patients' preference to include targeted resuscitation training for family members of individuals with high-risk for cardiac arrest as a part of out-of-hospital cardiac arrest intervention strategies.

Consensus-based quality standards for emergency departments in Palestine.

OBJECTIVES: The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine. METHODS: The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS. FINDINGS: We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes. CONCLUSION: This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges.

A Systematic Review of Cost-Effectiveness of Treating Out of Hospital Cardiac Arrest: Implications for Resource-limited Health Systems.

Background: Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources. Objective: To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings. Methods: The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints. Results: 468 unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in TOR protocols, professional prehospital defibrillator use, and CPR training followed by distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment. Conclusion: Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.

Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage.

Objectives: Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods: After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results: Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion: There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence: Not applicable.

Learning and retention of emergency first aid skills in a violent, developing South African township.

Community members in developing areas can effectively learn first responder training, and skill decay afterwards is not continuous. It is critical that training be done in the trainees' primary language, even if they speak other languages fluently. Making first responder training obligatory for employees and students may be an effective way to generate first responders.

Heart rate and systolic blood pressure in patients with minor to moderate, non-haemorrhagic injury versus normal controls.

BACKGROUND: Raised blood pressure (and heart rate (HR)) due to anxiety in a clinical situation is well described and is called the white coat effect (WCE). It is not known whether the pain and anxiety that results from trauma causes a measurable WCE. METHODS: A sample of patients with a non-haemorrhagic injury from the Trauma Audit and Research Network (TARN) was compared with a healthy, non-injury sample from the Health Survey for England (HSE) databases. Two-way analysis of variance with rank transformation of data was used to compare systolic blood pressure (SBP) and HR between the groups at different ages. In the injured group, the SBP and HR were also compared between spinally immobilised and non-immobilised patients. RESULTS: There was a statistically significant difference between the groups for both HR and SBP (p<0.001). Median HR remained approximately 10 bpm higher in the TARN set when compared to the HSE set, irrespective of age. The difference for SBP was not considered clinically relevant (the highest was 5 mm Hg). There was no significant difference between immobilised and non-immobilised patients, for either HR or SBP (p=0.07 and 0.3, respectively). DISCUSSION: Median HR remained approximately 10 bpm higher in the TARN (injury) set compared to the HSE (non-injury, control) set, irrespective of age. Understanding that HR reacts in this way for mild to moderately injured patients is important as it will affect clinical interpretation during the initial assessment.

Effect of spinal immobilization on heart rate, blood pressure and respiratory rate.

INTRODUCTION: Vital signs remain important clinical indicators in the management of trauma. Tissue injury and ischemia cause tachycardia and hypertension, which are mediated via the sympathetic nervous system (SNS). Spinal immobilization is known to cause discomfort, and it is not known how this might influence the SNS and contribute to abnormal vital signs. Hypothesis This study aimed to establish whether the pain and discomfort associated with spinal immobilization and the maneuvers commonly used in injured patients (eg, log roll) affect the Heart rate (HR), Systolic Blood Pressure (SBP) and Respiratory rate (RR). The null hypothesis was that there are no effects. METHODS: A prospective, unblinded, repeated-measure study of 53 healthy subjects was used to test the null hypothesis. Heart rate, BP and RR were measured at rest (five minutes), after spinal immobilization (10 minutes), following log roll, with partial immobilization (10 minutes) and again at rest (five minutes). A visual analog scale (VAS) for both pain and discomfort were also collected at each stage. Results were statistically compared. RESULTS: Pain VAS increased significantly during spinal immobilization (3.8 mm, P < .01). Discomfort VAS increased significantly during spinal immobilization, after log roll and during partial immobilization (17.7 mm, 5.8 mm and 8.9 mm, respectively; P < .001). Vital signs however, showed no clinically relevant changes. Discussion Spinal immobilization does not cause a change in vital signs despite a significant increase in pain and discomfort. Since no relationship appears to exist between immobilization and abnormal vital signs, abnormal vital signs in a clinical situation should not be considered to be the result of immobilization. Likewise, pain and discomfort in immobilized patients should not be disregarded due to lack of changes in vital signs.