Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review.

Background: Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods: A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results: A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions: This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration: PROSPERO CRD42019146802.

Permissive hypotension compared to fluid therapy for the management of traumatic haemorrhage: a rapid review.

Background: Haemorrhage and subsequent hypovolemia from traumatic injury is a potentially reversible cause of cardiac arrest, as interventions can be made to increase circulatory volume and organ perfusion. Traditionally, intravenous (IV) fluid therapy is recommended for all patients who have experienced a haemorrhagic emergency. There has been some argument, however, that this may not be the most effective treatment as isotonic fluids can dilute coagulation factors and further stimulate bleeding. Permissive hypotension, also known as hypotensive resuscitation within the context of damage control resuscitation, is a method of managing haemorrhagic trauma patients by restricting IV fluid administration to allow for a reduced blood pressure. It is important to evaluate and compare current research literature on the effects of both permissive hypotension and fluid therapy on patients suffering from traumatic haemorrhage. Methods: A rapid review was conducted by systematically searching and identifying literature to narratively compare permissive hypotension and fluid therapy. Searches were carried out across two databases to find relevant primary research containing quantitative data that provide contextual and statistical evidence to achieve the aim of this review. Papers were narratively synthesised to produce key themes for discussion. Results: The database searches identified 125 records, 78 from PubMed and 47 from ScienceDirect. Eleven duplicates were removed, and 114 titles screened. Ninety-four records were initially excluded and nine more after abstract review. Eleven papers were critiqued using Benton and Cormack's framework, with eight articles included in the final review. Conclusion: Permissive hypotension may have a positive impact on 30-day mortality, when compared with fluid resuscitation methods, however there is evidence to suggest that hypotensive resuscitation may be more effective for blunt force injuries. Some studies even suggest a reduction in the treatment cost when reducing fluid volumes. Penetrating injuries are usually more likely to be a compressible source of haemorrhage within which haemorrhage control can be gained much more easily. There are recommendations for the use of permissive hypotension in both compressible and non-compressible injuries. It is difficult at this time to draw definitive conclusions for the treatment of every case related to traumatic haemorrhage given the variability and unpredictability of trauma.

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

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

A descriptive study of demographics, triage allocations and patient outcomes at a private emergency centre in Pretoria.

BACKGROUND: Triage aims to detect critically ill patients and to prioritise those with time-sensitive needs, whilst contributing to the efficiency of an emergency centre (EC). International systems have been relatively well researched; however, little data exists on the use of the South African Triage Scale (SATS) in private healthcare settings in South Africa (SA). METHODS: A retrospective descriptive study was undertaken. Data relating to demographics, application of triage, time in EC and disposition were collected on all patients presenting to the EC from 1st January to 31st December 2018. RESULTS: A total of 29 055 patients' data were included. The mean age was 41 years. Most patients were triaged yellow (73.5%); 17.4% were triaged as red and orange. Patients were seen by a doctor in a mean time of 28 min. Delays to be seen exceeded standards for red and orange patients at 8 min and 18 min, respectively. Most patients (76.1%) were discharged; 5.6% were admitted to intensive care unit (ICU)/high care, and 14.4% to general wards. Of patients triaged red and orange, 11.1% and 49.3% were discharged, respectively, whereas 81.7% of yellow patients were discharged home. CONCLUSION: This study found that most patients were triaged into low acuity categories and were discharged home. High acuity patients were usually admitted to ICU/high care; however, these patients experienced delays in receiving treatment. The causes of these issues, and the implications, remain unknown. Large numbers of high acuity patients were discharged home. Further studies are needed to understand the influence of triage accuracy on these patients' outcomes.

Critical care service delivery across healthcare systems in low-income and low-middle-income countries: protocol for a systematic review.

INTRODUCTION: Critical care in low-income and low-middle income countries (LLMICs) is an underdeveloped component of the healthcare system. Given the increasing growth in demand for critical care services in LLMICs, understanding the current capacity to provide critical care is imperative to inform policy on service expansion. Thus, our aim is to describe the provision of critical care in LLMICs with respect to patients, providers, location of care and services and interventions delivered. METHODS AND ANALYSIS: We will search PubMed/MEDLINE, Web of Science and EMBASE for full-text original research articles available in English describing critical care services that specify the location of service delivery and describe patients and interventions. We will restrict our review to populations from LLMICs (using 2016 World Bank classifications) and published from 1 January 2008 to 1 January 2020. Two-reviewer agreement will be required for both title/abstract and full text review stages, and rate of agreement will be calculated for each stage. We will extract data regarding the location of critical care service delivery, the training of the healthcare professionals providing services, and the illnesses treated according to classification by the WHO Universal Health Coverage Compendium. ETHICS AND DISSEMINATION: Reviewed and exempted by the Stanford University Office for Human Subjects Research and IRB on 20 May 2020. The results of this review will be disseminated through scholarly publication and presentation at regional and international conferences. This review is designed to inform broader WHO, International Federation for Emergency Medicine and partner efforts to strengthen critical care globally. PROSPERO REGISTRATION NUMBER: CRD42019146802.

Prehospital care providers' understanding of responsibilities during a behavioural emergency.

BACKGROUND: Prehospital emergency care providers are frequently called to assist with the management of mental healthcare users (MHCUs). The Mental Health Care Act no. 17 of 2002 regulates mental healthcare in South Africa, but the act fails to consider the responsibilities of prehospital emergency care providers in the provision of mental healthcare. Rather South African Police Services were given authority over the well-being of a MHCU in the prehospital setting. AIM: To investigate prehospital emergency care providers' understanding of their responsibilities towards MHCUs and the community during the management of behavioural emergencies. SETTING: The research was carried out at prehospital emergency care providers from the three main levels of care, currently operational within the boundaries of Pretoria, South Africa. METHODS: A grounded theory qualitative study design was chosen using semi-structured focus groups for each level of prehospital emergency care - basic life support (BLS), intermediate life support (ILS) and advanced life support (ALS). Data from each focus group were collected through audio recordings and transcribed and analysed using a framework approach. RESULTS: A total of 19 prehospital emergency care providers participated; two focus group interviews were performed for each level of care. The BLS focus groups each consisted of two participants. The ILS focus groups consisted of three participants each, and the ALS focus groups consisted of six and three participants. Four key themes were identified: perceptions of behavioural emergencies, responsibilities, understanding of legislation and barriers experienced. CONCLUSION: Participants placed high value on their moral and medical responsibilities towards MHCUs, which they described as ensuring the safety of themselves, MHCUs and the community; preventing further harm; and transporting MHCUs to an appropriate healthcare facility. There was a desire for revision of legislation, better education, skill development and awareness of mental healthcare in the prehospital emergency care setting.

An epidemiological study of a patient population, triage category allocations and principal diagnosis within the emergency centres of a private healthcare group in the Emirate of Dubai, United Arab Emirates.

Aim: To describe, compare and correlate the number of patients seen, their demographics, triage category allocations and principal diagnosis in four emergency centres; to better understand the patient population and triage practices in this setting. Design: An observational, cross-sectional, epidemiological study. Methods: Electronic medical records were retrospectively evaluated from patients triaged in each of the four emergency centres over six months. Descriptive statistics were used to describe the patient demographics and variance between triage category allocations. Results: A total of 56,984 patient records were captured, with an equal gender split and the workforce being the largest patient population (20-50 years). Acute upper respiratory infection was the most prolific diagnosis, and lower acuity triage categories were allocated the most. There were inconsistencies in the application of triage systems between the emergency centres, the most obvious being the variance in triage system selection and application.

Reliability and validity of three international triage systems within a private health-care group in the Middle East.

AIM: To measure and compare the reliability and validity of three international triage systems (CTAS, MTS and ESI) when applied to patient presentations in the emergency centres of a private health-care group in the United Arab Emirates. BACKGROUND: The ability of triage systems to sort patients into categories based on the urgency of their need and time to physician is a key indicator. Three international triage systems are being used for this purpose in private emergency centre settings. METHOD: Bespoke reference scenarios, 50 vignettes (10 per severity level) were created and validated by a local expert panel. Nurses performing triage at four emergency centres in the Emirate of Dubai completed online surveys to categorise the vignettes based on the triage system they used in their emergency centre. RESULTS: Overall inter-rater reliability per triage category was substantial for allocations in category one, moderate for those in categories two and five, and fair for those in categories three and four. Agreement between raters and the reference standard was consistent throughout all four emergency centres. The accuracy of triaging allocations into categories one, two and five were good, whereas allocations in categories three and four were less accurate. CONCLUSION: International triage systems focus on the identification of more urgent cases and perform poorly in discriminating between those that are less serious, which is less ideal in a setting where less-serious cases are more prevalent.

The use of simulation as a teaching modality for paramedic education: a scoping review.

BACKGROUND: Simulation is a broad concept used as an education pedagogy for a wide range of disciplines. The use of simulation to educate paramedics is a frequently used but untested modality to teach psycho-motor skills, acquire new knowledge and gain competence in practice. This review identifies how simulation is currently being used for the education of paramedics, and establish the context for future application. METHODS: A scoping review of the literature was undertaken following the PRISMA systematic approach. Flexible inclusion criteria were used to capture research and non-research articles that would contribute to the synthesis of literature with a specific knowledge base pertaining to simulation use for paramedic education. RESULTS: Initial searching yielded 1388 records, of which 22 remained after initial title and abstract reading. Following secondary full-text screening, 18 articles were deemed appropriate for final inclusion: eight are research, two literature reviews and eight non-research. Across all the literature, a range of concepts are discussed: Skill vs Scenario, Virtual Learning, Inter-Professional Learning, Fidelity, Cost, Equipment, Improvement of Competency, Patient Safety, Perception of Simulation. CONCLUSION: It is evident that simulation is a primary teaching modality, consistently used to educate and train paramedics. Simulation is inherently effective at teaching clinical skills and building student competence in particular areas. Similarly, simulation is effective at providing paramedics with experiences and opportunities to learn in varied environments using differing techniques. This allows students to apply the relevant skills and knowledge when faced with real patients.

Emergency centre triage category allocations and their associated patient flow timeframes in a private healthcare group in the Middle East.

AIMS AND OBJECTIVES: To identify and describe triage category allocations and their associated patient pathway timeframes in four emergency centres of a large private healthcare group in the United Arab Emirates. BACKGROUND: The classification of patients in accordance with their acuity level is a complex task that requires quick and accurate allocation. Triage system categories have predetermined timeframes in which patients should be seen by a physician or treatment initiated for the best possible outcome. DESIGN AND METHODS: An observational, cross-sectional study was conducted through the prospective capture and evaluation of medical records from patients triaged in each of the four emergency centres (two hospitals and two clinics) over a period of a month. The STROBE statement was used as a reporting framework. Descriptive statistics were used to determine the timeframes associated with the patient pathway through each EC and contrasted against their allocated triage category. RESULTS: A total of 4,432 patient records were eligible for analysis from the four emergency centres. Triage category 4 (54.7%) was allocated the most with only a single category 1 patient seen between the four emergency centres. The median time from registration to triage was <10 min and triage to physician consult was <25 min. The overall length of stay of high-acuity cases was between 1 hr 13 min-2 hr 44 min, compared with low-acuity cases being 32-49 min. Overall time to physician was substantially lower than the targets set by the triage systems itself.

Pre-hospital intercostal chest drains in South Africa: A modified Delphi study.

INTRODUCTION: Trauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20-25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa. METHODS: A three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of 'strongly agree' or 'strongly disagree'. RESULTS: A total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%). CONCLUSION: Definitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently. The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa.

Pre-hospital intercostal chest drains in South Africa: A modified Delphi study

Introduction :Trauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20­25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain. The aim of this study was to seek expert opinion and consensus on the placement of ICDs in the pre-hospital emergency care setting in South Africa. Methods:A three-round modified Delphi study was undertaken with an expert panel drawn from local emergency care experts consisting of physicians and emergency medical service practitioners. Participants supplied opinion statements in round 1 under headings derived from common emerging themes found in the literature. During round 2 participants used a 9-point Likert scale to rate their consensus on each statement and in round 3 they were able to change their position based on the earlier panel distributions. A consensus percentage of 60% was set within a narrow margin of 'strongly agree' or 'strongly disagree'.Results : A total of 22 experts took part as panel members. There were 123 opinion statements produced from round 1, of which 21 (17%) reached consensus in round 2. At the end of round 3 another four statements reached consensus, bringing the total up to 25 (20%).Conclusio:Definitive care of a life-threating pneumothorax and/or haemothorax must be sought emergently.The insertion of an ICD, under select conditions, may be required in the pre-hospital setting in South Africa