Clinical features and outcomes of patients with preeclampsia and eclampsia at Gondar University hospital, Amhara, Ethiopia 2021.

Objective: The aim of this study was to investigate the clinical features, and treatment outcome of women with preeclampsia and eclampsia at Gondar University Comprehensive Specialized Hospital in Amhara, Northern Ethiopia, in 2021. Methods: An institutional-based retrospective chart review was conducted at Gondar University Specialized Hospital from March to June 2021. The study participants were chosen using a simple, systematic random sampling method. A pretested check list was used to collect data from medical records. The collected data was coded, entered into Epi-data version 4.6, and exported to SPSS version 26 for descriptive and inferential analysis. A Fisher's exact test was used to determine statistically significant factors at a p-value of < 0.05. Results: Of the 311 study participants, more than half (53 %) of mothers have illiterate, nearly half (49.8 %) had preeclampsia with severe features. Eclampsia accounted for 18.6 % of females in the study setting. For various reasons, more than half of the mothers required immediate intervention to terminate the pregnancy via cesarean section. Unfavorable maternal outcomes were present in more than 25 % of cases; the observed unfavorable maternal outcomes were aspiration pneumonia (10.6 %), hemolytic elevated liver function test and low platelet count syndrome (8.7 %), and maternal death (0.6 %). The severity of the disease, mode of delivery, aspartate transaminase, gravidity, gestational age, and antenatal care were all statistically significant predictors of pregnancy outcome. Conclusion: The prevalence of unfavorable maternal and perinatal outcomes of preeclampsia and eclampsia is considerable in the study area. To prevent these perinatal and postnatal effects, maternal outcomes of pregnancy, antenatal care services, emergency obstetrics, and new born care should be expanded and strengthened.

Reducing the length of stay of cardiac patients in the Adult Emergency department by using a Quality improvement framework.

BACKGROUND: Crowding is now a familiar challenge in the Emergency Department that can lead to significant adverse outcomes, including reduced quality of care and increased length of stay. OBJECTIVE: Reduce cardiac patient length of stay from 72 h to 48 h in the Tikur Anbessa Specialized Hospital Adult Emergency department from August 16, 2021, to January 29, 2022, in Addis Ababa, Ethiopia. METHODS: Process mapping was done by members of the team working in the emergency department on patient treatment and divided into three categories. Problems were then identified in each category that contributed to prolonged stay length. The run chart was then used to display the data for analysis, and nonrandom variation was looked for using the four-run chart rules. RESULTS: Improved patient throughput in the Emergency Department (ED) was achieved, reducing the average length of stay from 78 h to 25 h by implementing the following change strategies: Streamlining morning discharge times by adjusting from the baseline of 9:10 AM to 9:00 AM; Enhancing patient handover processes to ensure 100% of patients are included on the handover form during transition hours; and Consistently assigning residents to the waiting area, resulting in a 100% presence rate. These changes effectively decreased the prolonged patient length of stay in the ED. CONCLUSION: Poor management support and staff integration were identified as the leading cause of prolonged patient stay. In conclusion, a bundle of interventions is necessary to reduce the prolonged patient length of stay.

Determinants of hypertensive crisis among hypertensive patients at adult emergency departments of public hospitals in Addis Ababa, Ethiopia, 2021: a case-control study.

BACKGROUND: Hypertension (HTN) is a major global health problem that affects approximately 1.13 billion people worldwide, and 1-2% of this population has hypertensive crisis. Hypertensive crisis is becoming a major health issue in low-income countries. However, few studies have been conducted in developing countries such as Ethiopia. This study aimed to assess the determinants of hypertensive crisis among patients visiting adult emergency departments of public hospitals in Addis Ababa. METHOD: A hospital-based unmatched case-control study was conducted among 85 cases with a hypertensive crisis and 170 controls with hypertension without a hypertensive crisis in the adult emergency departments of public hospitals in Addis Ababa from March 15 to May 15, 2021. Data were collected using a structured questionnaire and analyzed using SPSS version 26. Binary logistic regression and multivariable logistic regression were performed. Finally, a statistically significant level was declared at a p value of less than 0.05. The result was summarized and presented in text, tables, and graph. RESULT: The odds of having hypertensive crisis were 3.6 times (AOR = 3.621) higher among participants with a history of hypertension compared to those without a history of hypertension. There was also 4 times increased risk of hypertensive crisis among participants who presented with diabetes mellitus than participants who presented without it (AOR = 4.179). Similarly, participants who presented with stroke had 7 times higher odds of having hypertensive crisis (AOR = 7.174) than participants without stroke. CONCLUSION: This study demonstrated a statistically significant association between unemployment, diabetes mellitus, stroke, heart failure, history of hypertension, family history of hypertension, and regular follow-up with a hypertensive crisis. The Ethiopian Ministry of Health, Ababa City Administration Health Bureau, and hospitals shall give due attention to the HTN crisis. Health care workers, hospital managers, and other stakeholders shall work towards the early detection and management of HTN-crisis to prevent related morbidity, disability, and mortality.

Facilitators and Barriers to National COVID 19 Guideline Adherence among Healthcare Providers in Ethiopia.

Background: Evidence-base practice needs to be supported by guidelines and decision-making protocols. This study aimed to look into the barriers and facilitators of adherence to national protocols in Ethiopia. Methods: Exploratory qualitative method was implemented to explore adherence to protocol. The national COVID-19 case management guideline was used as this study's prototype reference. A total of five FGDS were conducted among 26 healthcare providers. A total of 14 physicians and 12 nurses participated in the FGDs. Semi-structured focus group discussions guides were used to facilitate the discussion among healthcare workers involved in COVID-19 case management. The FGDs were audio recorded, transcribed and analyzed thematically. Results: Three broad themes have emerged from the content analysis. These include individual factors, environmental factors and system factors. System factors barriers to utilization include unclear guidelines, discordant guidelines and a lack of live national guidelines, while the main facilitator was supportive management. The environmental factors that were barriers to adherence included limited infrastructure and shortages of drugs suggested in the protocols. Conclusion: Outdated and discordant guidelines and a shortage of suggested managements were barriers. Future similar works should consider the identified barriers and need regular updates to facilitate effective implementation.

Prevalence and Antimicrobial Sensitivity Patterns of Uropathogens, in Tikur Anbessa Specialized Hospital Emergency Medicine Department Addis Ababa, Ethiopia.

Background: Empirical treatment of infections remains a major contributing factor to the emergence of pathogens that are resistant to antibiotics. The study aimed to assess the prevalence and anti-microbial sensitivity patterns of uropathogens in the Emergency Medicine Department of Tikur Anbessa Hospital, Ethiopia. Methods: Urine sample data collected over two years from January 2015 to January 2016 at Tikur Anbessa Hospital's laboratory were retrospectively analyzed for bacterial pathogens, and their antimicrobial susceptibility. Antimicrobial sensitivity tests were done using the disc diffusion technique as per the standard of the Kirby-Bauer method. Results: Of the total 220 samples that were collected, 50 (22.7%) were culture-positive. Male to female data ratio was 1:1.1. Escherichia coli was the dominant isolate (50%) followed by Enterococcus species (12%), Enterobacter species (12%), and Klebsiella species (8%). Overall resistance rates to Cotrimoxazole, Ampicillin, Augmentin, and Ceftriaxone were 90.4%, 88.8%, 82.5%, and 79.3%, respectively. The sensitivity rates for Chloramphenicol, Amikacin, Vancomycin, Meropenem, Cefoxitin, and Nitrofurantoin ranged from 72% to 100%. The antibiogram of isolates showed that 43 (86%) isolates were resistant to two or more antimicrobials, and 49 (98%) were resistant to at least one antibiotic. Conclusion and Recommendation: Urinary tract infections are mostly caused by Gram-negative bacteria predominantly in females and Escherichia coli are the most common isolates. Resistance rates to Cotrimoxazole, Ampicillin, Augmentin, and Ceftriaxone were high. Chloramphenicol, Amikacin, Vancomycin, Meropenem, Cefoxitin, and Nitrofurantoin are considered appropriate antimicrobials for the empirical treatment of complicated urinary tract infections in the emergency department. Yet, using antibiotics indiscriminately for patients with complicated UTIs may increase the resistance rate and also lead to treatment failure, hence the prescriptions should be revised following the culture and sensitivity results.

Knowledge, attitudes and beliefs about acute coronary syndrome among patients diagnosed with acute coronary syndrome, Addis Ababa, Ethiopia.

BACKGROUND: Acute coronary syndrome (ACS) morbidity and mortality are rising in low- and middle-income countries, including Ethiopia. The shift in health-care resources from communicable diseases to chronic conditions has created formidable health-care challenges. OBJECTIVE: The objective of this study was to examine the knowledge, attitudes and beliefs among ACS patients. METHODS: A cross-sectional design was used to enroll participants admitted to one of 3 emergency units in Addis Ababa, Ethiopia. Knowledge, attitudes and beliefs about ACS was measured using modified ACS response index questionaries. RESULTS: Participant's (N = 330) mean age was 57.9 ± 14.1, majority male (n = 219, 66.36%). Half of the study participants have inadequate Knowledge (n = 147, 44.6%), unfavorable attitudes (n = 152, 46%), and belief (n = 153, 46.4%) about ACS symptoms even after being diagnosed and treated in the emergency unit. The most frequently recognized ACS symptoms were chest discomfort (n = 274, 83%), fatigue (n = 267, 80.9%) and chest pain (n = 266, 80.6%) while Jaw pain (n = 101, 30%) neck pain (n = 146,44.2%), were less often recognized. Nearly two thirds of the participants (n = 214, 65%) would not prefer to use emergency medical services (EMS) to come to the hospital. Factors associated with adequate knowledge were age < 45 (AOR = 2.16, CI (1.1-4.0) p = 0.014), and female sex (AOR = 2.7, CI (1.5-4.4) p = 0.001) and diabetics (AOR = 1.9, (1.18-3.0) p = 0.008). Meanwhile, lack of formal education (AOR = 6.7, CI (3.1-14) p < 0.001) and unemployment (AOR = 2.0, CI (1.1-3.8) p = 0.021) were associated with unfavorable attitude. In addition, lack of social support (AOR = 1.9, (1.17-3.0) p = 0.009) and unfavorable attitude (AOR = 2.1, CI (1.3-3.4) p = 0.001) were significantly associated with unfavorable belief. CONCLUSION: Despite receiving treatment for ACS in an emergency unit, roughly half of participants did not have adequate knowledge, favorable attitude and belief towards ACS. This elucidates there is significant communication gap between the health care providers and patients. The study findings stipulate there is a need to provide health awareness campaigns using different media outlet with special attention to the uneducated and unemployed groups. Furthermore, most participants were less likely to utilize emergency medical service, which should be further investigated and addressed.

Characteristics and Outcomes of Mechanically Ventilated Patients at Adult ICU of Selected Public Hospitals in Addis Ababa, Ethiopia.

Introduction: Mechanical ventilation is the primary method of supporting organ function for patients admitted to intensive care units (ICU). The information on the characteristics and outcomes of patients requiring mechanical ventilation is essential to understanding the causes of mortality among mechanically ventilated patients. However, the available literature in developing countries, including Ethiopia, is limited. Objective: The objective of this study was to assess the characteristics and outcomes of mechanically ventilated patients in adult intensive care units in selected public hospitals, in Addis Ababa, Ethiopia, from 2019 to 2020. Methods: An institutional-based cross-sectional study design was employed. All adult patients who were mechanically ventilated and admitted to ICU for at least 24 hours between July 2019 and July 2020 were included in the study. The collected data were evaluated with SPSS version 26 software. Multiple logistic regression models were used to indicate the association between dependent and independent variables. The variables, which have an independent association with poor outcomes, were identified with a p-value less than 0.05. Results: Of 180 mechanically ventilated patients, 98(54.4%) were male. The main reason for ventilation was respiratory failure. The mean duration of stay on the ventilator was 7.09± 6.06, and the mortality rate in mechanically ventilated patients was 41.7%. The mortality rate was higher in patients with cardiac diseases 43(57.70%). Inotropic use, not taking sedation, and length of stay on a mechanical ventilator were independently associated with mortality. Conclusion: The mortality rate of mechanically ventilated patients in the selected public hospitals was high. The clinicians must strive to balance the necessity and benefit of sedation use with the potential to negatively affect the patient outcome. In addition, the risk:benefit assessment of ventilation must be done for all patients requiring ventilator support.

Treatment Seeking Behaviors and Associated Factors among Patients Experiencing Acute Coronary Syndrome Using Health Belief Model in Addis Ababa, Ethiopia.

Background: Acute coronary syndrome (ACS) is a life-threatening condition. The mortality rate will be reduced if immediate treatment is provided. Patients' awareness of ACS is limited, so they do not seek help as quite often as they should. The level of treatment seeking behavior and associated factors among ACS patients admitted to three hospitals in Addis Ababa, Ethiopia, were assessed using a health belief model. Methods: A cross-sectional study was conducted among 330 ACS patients from November 2019 to December 2020. Sociodemographic and clinical variables data were extracted using pre-tested checklist. The outcome and other variables data were collected using the checklist and structured questionnaire. The data were entered into Epi-data 3.1 and exported to STATA 17.1 for analysis. Descriptive statistics relevant to the variable was performed. A multivariable logistic regression was used to identify factors associated with treatment seeking behavior. Results: This study revealed that the mean time from symptom onset to arrival at the emergency unit (EU) was 24 ± 19.5 hours, slightly < half of the participants (n=149, 45.1 %) had adequate treatment seeking behavior. Perceived threat (AOR=1.03,95% CI:1.01-1.06, p=0.002), perceived benefits (AOR=1.09, 95%CI: 1.02-1.0, p≤0.001), self-efficacy (AOR=1.16, 95% CI :1.01- 1.22, p≤0.001), education (AOR=2.2,95%CI:1.31-3.9, p≤0.01) self-autonomy (AOR=3.1,95%CI:1.82-5.4, p<.001) and no depression (AOR=1.9,95%CI:1.1-3.3, p≤0.05) were found to have significantly association with adequate treatment seeking behavior. Conclusion: This study indicates, less than half of ACS patients had adequate treatment seeking behavior. Thus, context-specific behavioral interventions, along with public awareness campaigns about ACS, should be implemented.

Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis.

BACKGROUND: Despite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context. METHODS: We employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student's t-test to compare group means for percentage of scenarios with correct diagnosis. RESULTS: A total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98-1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88-1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges. CONCLUSION: We found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation. TRIAL REGISTRATION: Open Science Framework osf.io/ju4ga . Registered June 28, 2017.

Emergency capacity analysis in Ethiopia: Results of a baseline emergency facility assessment.

INTRODUCTION: In Ethiopia, the specialty of Emergency Medicine is a relatively new discipline. In the last few decades, policymakers have made Emergency Medicine a priority for improving population health. This study aims to contribute to this strengthening of Emergency Medicine, by conducting the country's first baseline gap analysis of Emergency Medicine Capacity at the pre-hospital and hospital level in order to help identify needs and areas for intervention. METHODS: This is a cross sectional investigation that utilized a convenience sampling of 22 primary, general and tertiary hospitals. Trained personnel visited the hospitals and conducted 4-hour interviews with hospital administrators and emergency care area personnel. The tool used in the interview was the Columbia University sidHARTe Program Emergency Services Resource Assessment Tool (ESRAT) to evaluate both emergency and trauma capacity in different regions of Ethiopia. The findings of this survey were then compared against two established standards: the World Health Organization's Essential Package of Emergency Care (EPEC), as well as those set by Ethiopia's Federal Ministry of Health. RESULTS: The tool assessed the services provided at each hospital and evaluated the infrastructure of emergency care at the facility. Triage systems differed amongst the hospitals surveyed though triaging and emergency unit infrastructures were relatively similar amongst the hospitals. There was a marked variability in the level of training, guidelines, staffing, disaster preparedness, drug availability, procedures performed, and quality assurance measures from hospital to hospital. Most regional and district hospitals did not have nurses or doctors trained in Emergency Medicine and over 70% of the hospitals did not have written guidelines for standardized emergency care. CONCLUSION: This gap analysis has revealed numerous inconsistencies in health care practice, resources, and infrastructure within the scope of Emergency Medicine in Ethiopia. Major gaps were identified, and the results of this assessment were used to devise action priorities for the Ministry of Health. Much remains to be done to strengthen Emergency Medicine in Ethiopia, and numerous opportunities exist to make additional short and long-term improvements.

Clinical Characteristics of COVID-19 Related Deaths in Ethiopia.

BACKGROUND: Since the occurrence of COVID-19 in the world, it has claimed nearly 1.39 million human lives in the world and more than 1500 lives in Ethiopia. The number of deaths is increasing with variable distribution in the world. Despite its increasing fatality, the clinical characteristics of the deceased patients are not yet fully known. Analyzing the clinical characteristics of deceased patients will help to improve the outcome of infected patients. Hence, this study aimed to determine the clinical characteristics of patients who died due to COVID-19 in Ethiopia. METHODS: Hospital based multi-center cross-sectional study was conducted using chart review of deceased patients. Since the number of COVID-19 related deaths was limited, all consecutive COVID-19 related hospital deaths were analyzed. The data was entered into and analyzed using SPSS version 25.0. Descriptive statistics was used to explain the data collected from the survey. RESULT: A total of 92 deceased patient charts were analyzed. Of these patients, 65(71%) were males. Age ranged from 17 to 92 years (mean age being 59 years). On arrival vital signs, 60.5% of them had hypoxia, 49% had tachycardia and only 32% of patients had fever. Three fourth of the patients 64/85 had at least one comorbidity. Diabetes mellitus (DM) was the commonest comorbidity accounting for 445.9%, followed by hypertension, 23/85(27%), and HIV/ AIDS, 15/85 (17.5%). CONCLUSION: The results of this study showed that COVID-19 deceased patients presented with respiratory failure and hypoxia. However, less than a third of these patients had fever. In addition, the presence of comorbid illnesses and non-COVID-19 diseases like AIDS defining illness in significant amount needs further study to identify their level of contribution to the increasing burden of COVID-19 deaths in Ethiopia.

Clinical and Socio-demographic Profile of the First 33 COVID-19 Cases Treated at Dedicated Treatment Center in Ethiopia.

BACKGROUND: Severe respiratory tract infection caused by family of Corona viruses has become world pandemic. The purpose of this study was to describe the first few COVID 19 cases in Ethiopia. METHOD: Descriptive study was conducted on the first 33 consecutive RT-PCR confirmed COVID 19 cases diagnosed and managed at Ekka-Kotebe COVID Treatment Center in Addis Ababa, Ethiopia. RESULT: The median age of the cases was 36 years. Cough, headache and fever were the most frequent symptoms. Diarrhea, sore throats, loss of taste and/or smell sensation were among the rare symptoms. Most (84.8%) had mild to moderate disease, and 15.2%(n=5) were critical at the time of admission. Among the five ICU admissions, four patients required invasive mechanical ventilation. Thirty cases were discharged after two pairs of nasopharyngeal and oropharyngeal samples turned negative for SARS CoV2. Three cases from the ICU died while on mechanical ventilator. The age of the two deaths was 65 years, and one was 60 years. With the exception of three, all cases were either imported from abroad or had contact with confirmed cases. CONCLUSION: Most of our patients were in the younger age group with male predominance and few with comorbidities. Cough was the commonest symptom followed by headache and fever. As it was in the early stage of the pandemic, observation of more cases in the future will reveal further clinical and demographic profiles of COVID-19 cases in Ethiopia.

Clinical and socio-demographic profile of the first 33 COVID-19 cases treated at dedicated treatment center in Ethiopia

BACKGROUND:Severe respiratory tract infection caused by family of Corona viruses has become world pandemic. The purpose of this study was to describe the first few COVID 19 cases in Ethiopia. METHOD: Descriptive study was conducted on the first 33 consecutive RT-PCR confirmed COVID 19 cases diagnosed and managed at Ekka-Kotebe COVID Treatment Center in Addis Ababa, Ethiopia. RESULT: The median age of the cases was 36 years. Cough, headache and fever were the most frequent symptoms. Diarrhea, sore throats, loss of taste and/or smell sensation were among the rare symptoms. Most (84.8%) had mild to moderate disease, and 15.2%(n=5) were critical at the time of admission. Among the five ICU admissions, four patients required invasive mechanical ventilation. Thirty cases were discharged after two pairs of nasopharyngeal and oropharyngeal samples turned negative for SARS CoV2. Three cases from the ICU died while on mechanical ventilator. The age of the two deaths was 65 years, and one was 60 years. With the exception of three, all cases were either imported from abroad or had contact with confirmed cases. CONCLUSION: Most of our patients were in the younger age group with male predominance and few with comorbidities. Cough was the commonest symptom followed by headache and fever. As it was in the early stage of the pandemic, observation of more cases in the future will reveal further clinical and demographic profiles of COVID-19 cases in Ethiopia

Cochrane, evidence-based medicine and associated factors: A cross-sectional study of the experiences and knowledge of Ethiopian specialists in training.

INTRODUCTION: Evidence-based healthcare is a core competency for practicing healthcare practitioners and those in speciality training. In sub-Saharan Africa, little is known about the teaching of evidence-based medicine (EBM) in residency program. This survey evaluated the experiences and knowledge of Cochrane, EBM and associated factors among Ethiopian specialists in training. METHODS: A convenient sample of trainee specialists completed a pretested self-administered survey. The majority (93%) were ≤30 years old, males (63%) and 41% in paediatrics speciality. The associations of categorical variables with EBM knowledge was assessed by Fisher's exact or Chi-Square tests. Covariates contributing to EBM knowledge were identified using multivariate logistic regression analysis. RESULTS: Eighty-three trainees participated in the survey (response rate 88.2%). About 75% have heard about Cochrane but no one recognized Cochrane South Africa. Only 25% of the trainees knew the Cochrane Library but none used it in clinical practice. Most (78%) have heard of EBM, 15% had attended EBM course, 96% wanted to attend EBM course and 81% had positive attitudes to EBM. Trainees EBM knowledge was associated with awareness of Cochrane [Adjusted odds ratio (AOR) = 8.5, 95% Confidence interval (CI) 1.3-54.6, P = 0.02], EBM (AOR = 51.2, 95% CI 2.7-960.8, P = 0.009), and being in third year training (AOR = 28.4, 95% CI 1.9-427.2, P = 0.02). The promotion of EBM in residency hospital (AOR = 22.2, 95% CI 2.2-223.8, P = 0.008) and being aware of Cochrane (AOR = 4.8, 95% CI 1.1-21.7, P = 0.04) were predictors of positive attitude. Familiarity with Cochrane Library was influenced by EBM knowledge (AOR = 6.6, 95% CI 1.4-31.5, P = 0.02) and perceived organization barrier to accessing the resource (AOR = 3.2, 95% CI 1.03-10.1, P = 0.04). CONCLUSION: Ethiopian trainee specialists lacked formal EBM training, awareness and use of the Cochrane Library. To improve the healthcare quality and patient outcomes, EBM education should be integrated into residency curricula.

Mixed methods process evaluation of pilot implementation of the African Federation for Emergency Medicine trauma data project protocol in Ethiopia.

INTRODUCTION: The African Federation for Emergency Medicine Trauma Data Project (AFEM-TDP) has created a protocol for trauma data collection in resource-limited settings using a clinical chart with embedded standardized data points that facilitates a systematic approach to injured patients. We performed a process evaluation of the protocol's implementation at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia to provide insights for adapting the protocol to our setting. METHODS: During the pilot implementation period, the quality of collected data was assessed. Structured key informant interviews about participant experiences and perceptions of the protocol implementation were then conducted. Interviews were analysed using a SWOT model. RESULTS: During pilot data collection, the overall capture rate was 21%. Variables collected with high frequency included demographics, vital signs and ED diagnosis, while mechanism of injury and ED disposition were often missed. Key informant interviews identified Strengths, Weaknesses, Opportunities and Threats to the protocol. Strengths included improved patient care, enhanced training for junior providers and facilitated data collection. Weaknesses included inadequate supervision and challenges relating to the physical size of the form, which resulted in missing data. Opportunities included retrospective research and quality improvement work. Threats included perceived lack of a local champion, poor buy-in from other hospital departments and need for ongoing financial support. CONCLUSION: A mixed methods process evaluation is an invaluable tool when implementing novel data collection protocols, especially in resource-limited settings. We determined early successes and challenges of the implementation of the AFEM-TDP protocol and generated strategies to adapt the protocol to better suit our setting. Lessons from this process evaluation may be informative for other researchers designing and implementing similar data collection protocols.

Profile of Head Injuries: Prehospital Care, Diagnosis, and Severity in an Ethiopian Tertiary Hospital.

BACKGROUND: Consistent data on head injury is lacking especially in the low- and middle-income countries. Our study tries to characterize patients with head injury at the emergency department of one of the few tertiary public hospitals giving neurosurgical care in the country. METHODS: A retrospective cross-sectional study was performed from May 2015 to October 2015 in one of the neurosurgical teaching hospitals, Black Lion Specialized Hospital. All adult patients with head injury who visited the emergency department during the study period were included. Data on patients' sociodemographic, mechanism of trauma, clinical presentation, imaging findings, and presence of polytrauma were collected by a pretested questionnaire. The source of data was emergency department logbooks and patient charts. RESULTS: A total of 390 patients with head injury who visited the emergency department were included during the study period. There were 335 males (85.9%) and 55 females (14.1%) with the mean age (standard deviation) of 35.4 (15.6) years. Majority of patients came by taxi constituting 149 (38.2%) of all patients, whereas 147 patients (37.7%) used ambulance. Of 147 patients brought by ambulances, 133 (90.4%) were referred from other hospitals. The majority, 26 (45.6%), of patients who came directly to the emergency department used taxis. It is shown that the mode of arrival and origin of arrival are significantly related, P = 0.000. Mortality of severe head injury at the emergency department was 50.8%. CONCLUSIONS: Prehospital care coverage was low and ambulances were used mainly for interhospital transfers. Mortality of severe head injury at the emergency department is high and significantly associated with preventable causes like vital sign derangement.

Barriers to and facilitators of the development and utilization of context appropriate evidence based clinical algorithms to optimize clinical care and patient outcomes in the Tikur Anbessa emergency department: a multi-component qualitative study.

BACKGROUND: Evidence-based clinical algorithms (EBCA) are knowledge tools to promote evidence use by codifying evidence into action plans to facilitate appropriate care. However, their impact on process and outcomes of care varies considerably across practice settings and providers, highlighting the need for tailoring of both these knowledge tools and their implementation strategies to target end users and the setting in which EBCAs are to be employed. Leadership at the Tikur Anbessa Specialized Hospital emergency department (TASH-ED) in Addis Ababa, Ethiopia identified a need for context-appropriate EBCAs to improve evidence uptake to mitigate care gaps in this high volume, high acuity setting. We aimed to identify barriers and facilitators to utilization of EBCAs in the TASH-ED, to identify priority targets for development of EBCAs tailored for the TASH-ED context and to understand the process of care in the TASH-ED to inform implementation planning. METHODS: We employed a multi-component qualitative design including: semi-structured interviews with TASH-ED clinical, administrative and support services staff, and Toronto EM physicians who had worked in the TASH-ED; direct observation of the process of care in TASH-ED; document review. RESULTS: Although most TASH-ED participants reported an awareness of EBCAs, they noted little or no experience using them, primarily due to the poor fit of many EBCAs to their practice setting. All participants felt that context-appropriate EBCAs were needed to ensure standardized and evidence-based care and improve patient outcomes for common ED presentations. Trauma, sepsis, acute cardiac conditions, hypertensive emergencies, and diabetic keto-acidosis were most commonly identified as priorities for EBCA development. Lack of medication, equipment and human resources were identified as the primary barriers to use of EBCAs in the TASH-ED. Support from leadership and engagement of stakeholders outside the ED where EBCAs were believed to be less well accepted were identified as essential facilitators to implementation of EBCAs in the TASH-ED. CONCLUSIONS: This study found a perceived need for EBCAs tailored to the TASH-ED setting to support uptake of evidence-based care into routine practice for common clinical presentations. Barriers and facilitators provide information essential to development of both context-appropriate EBCAs and plans for their implementation in the TASH-ED.

Injury severity levels and associated factors among road traffic collision victims referred to emergency departments of selected public hospitals in Addis Ababa, Ethiopia: the study based on the Haddon matrix.

BACKGROUND: Globally, about 1.25 million people die annually from road trafficcollisions. Evidence from global safety report shows a decreasing trend of road traffic injury indeveloped countries while there is an increasing trend in many developing countriesincluding Ethiopia. This study is aimed at assessing factors affecting injury severity levels of road traffic collision victims referred to selected public hospitals in Addis Ababa based on the Haddon Matrix. METHODS: Ahospital-based cross-sectional study designwas implemented to randomly select a total of 363 road traffic collision victims. The collected data was cleaned andentered into Epidata version 3.1 and exported to SPSS Version 21 for analysis. Bivariate and multivariate logisticregression models were used to examine the association between explanatory and outcome variables. RESULTS: A total of 363 individual sustained road traffic injuries were included to the study. Theprevalence of severe injury among road traffic accident victims was 36.4%. The following variables were significantly associated with increased injury severity: motorbike rider or motorbike passenger without helmet, adjusted odds ratio (AOR) 4.7(95% CI: 1.04-21.09); driving under the influence of alcohol, crude odds ratio (COR) 2.64(95% CI;1.23-5.64); victim with multiple injuries, AOR 3.88(95% CI: 2.26-6.65); vehicle size, AOR 2.14(95% CI: 1.01-4.52); collision in dark lighting condition, AOR 1.93(95% CI: 1.01-3.65); collision in cross city/rural, AOR 1.95(95% CI: 1.18-3.24) and vehicle occupant travelling unrestrained on the back of a truck, AOR3.9 (95% CI: 1.18-12.080). On the other hand, victims extricated at the scene by health care professional, AOR 0.33(95% CI: 0.13-0.83); victims extricated at the scene by police AOR 0.47(95% CI: 0.24-0.94); strict traffic police control at the scene of the collision, AOR 0.49(95% CI: 0.27-0.88) were significantly associated with less severe injuries. CONCLUSIONS: Findings reported in this paper suggest the need forimmediate and pragmatic steps to be taken to curb the unnecessary loss of livesoccurring on the roads. In particular, there is urgent need to introduce road safety interventions.

Cochrane, evidence-based medicine and associated factors: A cross-sectional study of the experiences and knowledge of Ethiopian specialists in training

Introduction: Evidence-based healthcare is a core competency for practicing healthcare practitioners and those in speciality training. In sub-Saharan Africa, little is known about the teaching of evidence-based medicine (EBM) in residency program. This survey evaluated the experiences and knowledge of Cochrane, EBM and associated factors among Ethiopian specialists in training.Methods: A convenient sample of trainee specialists completed a pretested self-administered survey. The majority (93%) were ≤30 years old, males (63%) and 41% in paediatrics speciality. The associations of categorical variables with EBM knowledge was assessed by Fisher's exact or Chi-Square tests. Covariates contributing to EBM knowledge were identified using multivariate logistic regression analysis.Results: Eighty-three trainees participated in the survey (response rate 88.2%). About 75% have heard aboutCochrane but no one recognized Cochrane South Africa. Only 25% of the trainees knew the Cochrane Library but none used it in clinical practice. Most (78%) have heard of EBM, 15% had attended EBM course, 96% wanted to attend EBM course and 81% had positive attitudes to EBM. Trainees EBM knowledge was associated withawareness of Cochrane [Adjusted odds ratio (AOR) = 8.5, 95% Confidence interval (CI) 1.3­54.6, P = 0.02], EBM (AOR = 51.2, 95% CI 2.7­960.8, P = 0.009), and being in third year training (AOR = 28.4, 95% CI 1.9­427.2, P = 0.02). The promotion of EBM in residency hospital (AOR = 22.2, 95% CI 2.2­223.8, P = 0.008) and being aware of Cochrane (AOR = 4.8, 95% CI 1.1­21.7, P = 0.04) were predictors of positive attitude. Familiarity with Cochrane Library was influenced by EBM knowledge (AOR = 6.6, 95% CI 1.4­31.5, P = 0.02) and perceived organization barrier to accessing the resource (AOR = 3.2, 95% CI 1.03­10.1, P = 0.04). Conclusion: Ethiopian trainee specialists lacked formal EBM training, awareness and use of the Cochrane Library. To improve the healthcare quality and patient outcomes, EBM education should be integrated into residency curricula

Feasibility of telephone-administered interviews to evaluate long-term outcomes of trauma patients in urban Ethiopia.

BACKGROUND: Little is known about long-term functional outcomes of trauma patients in low-income and middle-income countries. In sub-Saharan Africa most studies of injury only collect data through emergency department disposition or hospital discharge, and methods of collecting long-term data are subject to significant bias. With the recent increase in access to mobile telephone technology, we hypothesized that structured, telephone-administered interviews now offer a feasible means to collect data about the long-term functional outcomes of trauma patients in urban Ethiopia. METHODS: We piloted a telephone-administered interview tool based on the Glasgow Outcome Scale-Extended. Using departmental logbooks, 400 consecutive patients presenting to two public referral hospitals were identified retrospectively. Demographics, injury data, and telephone numbers were collected from medical records. When a telephone number was available, patients or their surrogates were contacted and interviewed 6 months after their injuries. RESULTS: We were able to contact 47% of subjects or their surrogates, and 97% of those contacted were able and willing to complete an interview. At 6-month follow-up, 22% of subjects had significant persistent functional disability. Many injuries had an ongoing financial impact, with 17% of subjects losing or changing jobs, 18% earning less than they had before their injuries, and 16% requiring ongoing injury-related medical care. Lack of documented telephone numbers and difficulty contacting subjects at recorded telephone numbers were the major obstacles to data collection. Language barriers and respondents' refusal to participate in the study were not significant limitations. DISCUSSION: In urban Ethiopia, many trauma patients have persistent disability 6 months after their injuries. Telephone-administered interviews offer a promising method of collecting data about the long-term trauma outcomes, including functional status and the financial impact of injury. These data are invaluable for capacity building, quality improvement efforts, and advocacy for injury prevention and trauma care. LEVEL OF EVIDENCE: III, retrospective cohort study.