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BACKGROUND: Emergency medicine (EM) in Brazil has achieved critical steps toward its development in the last decades including its official recognition as a specialty in 2016. In this article, we worked in collaboration with the Brazilian Association of Emergency Medicine (ABRAMEDE) to describe three main aspects of EM in Brazil: (1) brief historical perspective; (2) current status; and (3) future challenges. MAIN TEXT: In Brazil, the first EM residency program was created in 1996. Only 20 years later, the specialty was officially recognized by national regulatory bodies. Prior to recognition, there were only 2 residency programs. Since then, 52 new programs were initiated. Brazil has now 54 residency programs in 16 of the 27 federative units. As of December 2020, 192 physicians have been board certified as emergency physicians in Brazil. The shortage of formal EM-trained physicians is still significant and at this point it is not feasible to have all Brazilian emergency care units and EDs staffed only with formally trained emergency physicians. Three future challenges were identified including the recognition of EM specialists in the house of Medicine, the need of creating a reliable training curriculum despite highly heterogeneous emergency care practice across the country, and the importance of fostering the development of academic EM as a way to build a strong research agenda and therefore increase the knowledge about the epidemiology and organization of emergency care. CONCLUSION: Although EM in Brazil has accomplished key steps toward its development, there are several obstacles before it becomes a solid medical specialty. Its continuous development will depend on special attention to key challenges involving recognition, reliability, and research.
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INTRODUCTION: Triage protocols standardize and improve patient care in accident and emergency departments (A&Es). Kenyatta National Hospital (KNH), the largest public tertiary hospital in East Africa, is resource-limited and was without A&E-specific triage protocols. OBJECTIVES: We sought to standardize patient triage through implementation of the South African Triage Scale (SATS). We aimed to (1) assess the reliability of triage decisions among A&E healthcare workers following an educational intervention and (2) analyze the validity of the SATS in KNH's A&E. METHODS: Part 1 was a prospective, before and after trial utilizing an educational intervention and assessing triage reliability using previously validated vignettes administered to 166 healthcare workers. Part 2 was a triage chart review wherein we assessed the validity of the SATS in predicting patient disposition outcomes by inclusion of 2420 charts through retrospective, systematic sampling. RESULTS: Healthcare workers agreed with an expert defined triage standard for 64% of triage scenarios following an educational intervention, and had a 97% agreement allowing for a one-level discrepancy in the SATS score. There was "good" inter-rater agreement based on an intraclass correlation coefficient and quadratic weighted kappa. We analyzed 1209 pre-SATS and 1211 post-SATS patient charts and found a non-significant difference in undertriage and statistically significant decrease in overtriage rates between the pre- and post-SATS cohorts (undertriage 3.8 and 7.8%, respectively, p = 0.2; overtriage 70.9 and 62.3%, respectively, p < 0.05). The SATS had a sensitivity of 92.2% and specificity of 37.7% for predicting admission, death, or discharge in the A&E. CONCLUSION: Healthcare worker triage decisions using the SATS were more consistent with expert opinion following an educational intervention. The SATS also performed well in predicting outcomes with high sensitivity and satisfactory levels of both undertriage and overtriage, confirming the SATS as a contextually appropriate triage system at a major East African A&E.
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BACKGROUND: Resource-limited settings are increasingly experiencing a 'triple burden' of disease, composed of trauma, non-communicable diseases (NCDs) and known communicable disease patterns. However, the epidemiology of acute and emergency care is not well characterised and this limits efforts to further develop emergency care capacity. OBJECTIVE: To define the burden of disease by describing the patient population presenting to the Accident and Emergency Department (A&E) at Kenyatta National Hospital (KNH) in Kenya. METHODS: We completed a prospective descriptive assessment of patients in KNH's A&E obtained via systematic sampling over 3 months. Research assistants collected data directly from patients and their charts. Chief complaint and diagnosis codes were grouped for analysis. Patient demographic characteristics were described using the mean and SD for age and n and percentages for categorical variables. International Classification of Disease 10 codes were categorised by 2013 Global Burden of Disease Study methods. RESULTS: Data were collected prospectively on 402 patients with an average age of 36 years (SD 19), and of whom, 50% were female. Patients were most likely to arrive by taxi or bus (39%), walking (28%) or ambulance (17%). Thirty-five per cent of patients were diagnosed with NCDs, 24% with injuries and 16% with communicable diseases, maternal and neonatal conditions. Overall, head injury was the single most common final diagnosis and occurred in 32 (8%) patients. The most common patient-reported mechanism for head injury was road traffic accident (39%). CONCLUSION: This study estimates the characteristics of the A&E population at a tertiary centre in Kenya and highlights the triple burden of disease. Our findings emphasise the need for further development of emergency care resources and training to better address patient needs in resource-limited settings, such as KNH.