What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda.

OBJECTIVES: To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients. SETTING: A single emergency department (ED) of a district-level hospital in rural Uganda. PARTICIPANTS: 26 710 patient visits. RESULTS: Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. CONCLUSION: This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.

Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda.

BACKGROUND: A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care. METHODS: A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ(2) tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality. RESULTS: Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were "severely ill." The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47). CONCLUSIONS: Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients.

Mortality related to acute illness and injury in rural Uganda: task shifting to improve outcomes.

BACKGROUND: Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients. METHODS: Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department's quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit. FINDINGS: Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives. INTERPRETATION: This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.

Point-of-care ultrasound education for non-physician clinicians in a resource-limited emergency department.

OBJECTIVE: To describe the outcomes and curriculum components of an educational programme to train non-physician clinicians working in a rural, Ugandan emergency department in the use of POC ultrasound. METHODS: The use of point-of-care ultrasound was taught to emergency care providers through lectures, bedsides teaching and hands-on practical sessions. Lectures were tailored to care providers' knowledge base and available therapeutic means. Every ultrasound examination performed by these providers was recorded over 4.5 years. Findings of these examinations were categorised as positive, negative, indeterminate or procedural. Other radiologic studies ordered over this same time period were also recorded. RESULTS: A total of 22,639 patients were evaluated in the emergency department by emergency care providers, and 2185 point-of-care ultrasound examinations were performed on 1886 patients. Most commonly used were the focused assessment with sonography in trauma examination (53.3%) and echocardiography (16.4%). Point-of-care ultrasound studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all examinations. CONCLUSIONS: We describe a novel curriculum for point-of-care ultrasound education of non-physician emergency practitioners in a resource-limited setting. These non-physician clinicians integrated ultrasound into clinical practice and utilised this imaging modality more frequently than traditional radiology department imaging with a large proportion of positive findings.

World Health Assembly Resolution 60.22. [corrected].

The World Health Assembly 2007 Resolution 60.22 tasked the global health community to address the lack of emergency care in low- and middle-income countries. Little progress has yet been made in integrating emergency care into most low- and middle-income-country health systems. At a rural Ugandan district hospital, however, a collaborative between a nongovernmental organization and local and national stakeholders has implemented an innovative emergency care training program. To our knowledge, this is the first description of using task shifting in general hospital-based emergency care through creation of a new nonphysician clinician cadre, the emergency care practitioner. The program provides an example of how emergency care can be practically implemented in low-resource settings in which physician numbers are limited. The Ministry of Health is directing its integration into the national health care system as a component of a larger ongoing effort to develop a tiered emergency care system (out-of-hospital, clinic- and hospital-based provider and physician trainings) in Uganda. This tiered emergency care system is an example of a horizontal health system advancement that offers a potentially attractive solution to meet the mandate of World Health Assembly 60.22 by providing inexpensive educational interventions that can make emergency care truly accessible to the rural and urban communities of low- and middle-income countries.

Nurse-administered ketamine sedation in an emergency department in rural Uganda.

STUDY OBJECTIVE: We determine whether, after a brief training program in procedural sedation, nurses can safely independently administer ketamine sedation in a resource-limited environment. METHODS: This is an observational case series of consecutive sedations performed in an emergency department in rural Uganda at approximately 5,000 feet above sea level. The data were collected prospectively in a quality assurance database. As part of a larger training program in emergency care at Karoli Lwanga Hospital in rural Uganda, nurses with no sedation experience were trained in procedural sedation with ketamine. All sedations were monitored by a nonphysician research assistant, who recorded ketamine dosing, duration of each procedure, adverse events, and nurse interventions for each adverse event. In accordance with standard definitions in the emergency medicine sedation literature, adverse events were defined a priori and classified as major (death, need for bag-valve-mask ventilation, or unanticipated admission to the hospital) or minor (hypoxia, vomiting, emergence reactions, hypersalivation). The primary statistical analysis was descriptive, with reporting of adverse event rates with 95% confidence intervals (CIs), using the nurse as the unit of analysis. RESULTS: There were a total of 191 administrations by 6 nurses during the study period (December 2009 through March 2010). Overall, there was an 18% adverse event rate (95% CI 7% to 30%), which is similar to the rate reported in resource-rich countries. These events included hypoxia (22 cases; 12%), vomiting (9 cases; 5%), and emergence reaction (7 cases; 4%). All adverse events met our a priori defined criteria for minor events, with a 0% incidence of major events (1-sided 97.5% CI with the nurse as unit of analysis 0% to 46%). The procedural success rate was 99%. Sedation was practitioner rated as "excellent" in 91% of cases (95% CI 86% to 94%) and "good" in 9% (95% CI 6% to 14%). Patients reported they would want ketamine for a future procedure in 98% of cases (95% CI 95% to 100%). CONCLUSION: In resource-limited settings, nurse-administered ketamine sedation appears to be safe and effective. A brief procedural sedation training program, coupled with a comprehensive training program in emergency care, can increase access to appropriate and safe sedation for patients in resource-limited settings.

Alcohol-related hypoglycemia in rural Uganda: socioeconomic and physiologic contrasts.

Hypoglycemia is a rare but important complication seen in patients who present with alcohol intoxication. In a study by Marks and Teale, less than one percent of people with alcohol intoxication who presented to an American emergency department were hypoglycemic [1]. It is even more rare to see an intoxicated patient, who had been eating appropriately prior to or during the intoxication, present in a hypoglycemic coma. However, our analysis of the first 500 patients seen in a newly opened five-bed Emergency Department (ED) at Nyakibale Karoli Lwanga Hospital in rural southwestern Uganda, revealed multiple intoxicated patients who presented in hypoglycemic coma within hours of eating a full meal. Three of these cases are summarized and discussed below.

Emergency department presentations of transverse myelitis: two case reports.

Transverse myelitis, a diagnosis that may be made in the emergency department (ED) by emergency physicians, can be difficult to diagnose because of its variable signs and symptoms and its poorly understood pathogenesis. In this article, we recount 2 cases of transverse myelitis to demonstrate its presentation, diagnosis, and management in the ED.