Emergency department antimicrobial use in a low-resource setting: results from a retrospective observational study at a referral hospital in Liberia.

OBJECTIVE: Data on antimicrobial use in low-income and middle-income countries (LMICs) remain limited. In Liberia, the absence of local data impedes surveillance and may lead to suboptimal treatment, injudicious use and resistance against antimicrobials. This study aims to examine antimicrobial prescribing patterns for patients in the emergency department (ED) of a large Liberian public hospital. Secondarily, this prescribing was compared with WHO prescribing indicators. DESIGN: Retrospective observational study. SETTING: An adult ED of a large public hospital in Monrovia, Liberia. PARTICIPANTS: A total of 1082 adult patients (>18 years of age) were recorded in the ED, from 1 January to 30 June 2019. MAIN OUTCOME MEASURES: Number, type and name of antimicrobials ordered per patient were presented as number and percentages, with comparison to known WHO prescribing indicators. Pearson χ2 tests were used to assess patient variables and trends in medication use. RESULTS: Of the total patients, 44.0% (n=476) were female and the mean age was 40.2 years (SD=17.4). An average of 2.78 (SD=2.02) medicines were prescribed per patient encounter. At least one antimicrobial was ordered for 64.5% encounters (n=713) and two or more antimicrobials for 35.7% (n=386). All antimicrobial orders in our sample used the generic name. Ceftriaxone, metronidazole and ampicillin were the most common and accounted for 61.2% (n=743) of antimicrobial prescriptions. The majority (99.9%, n=1211) of antimicrobials prescribed were from the WHO Essential Drugs List. CONCLUSION: This study is one of the first on ED-specific antimicrobial use in LMICs. We revealed a high rate of antimicrobial prescription, regardless of patient demographic or diagnosis. While empiric antimicrobial use is justified in certain acute clinical scenarios, the high rate from this setting warrants further investigation. The results of this study underscore the importance of ED surveillance to develop targeted antimicrobial stewardship interventions and improve patient care.

A Global Review of Provisions on Emergency Care in National Constitutions.

National constitutions are important tools for the realization of the right to health, and constitutional law linking health and human rights has been associated with improved access to health resources. Meanwhile, emergency care is a lifesaving service delivery platform with the potential to address much of the death and disability in low- and middle-income countries (LMICs). Yet even where services exist, access to emergency care may be systematically limited for vulnerable populations, except where laws explicitly protect the right to emergency care. We therefore sought to catalog and describe constitutional provisions related to emergency care. Through a comprehensive review of 195 national constitutions, we searched provisions for terms related to emergency care and performed qualitative framework analysis on these provisions. Eleven provisions met inclusion criteria, representing ten LMICs with constitutions written since 1996. While seven of the eleven provisions guarantee access to emergency care to all people, three narrow this guarantee to citizens only. Only three constitutions address the affordability of emergency care. While these constitutional provisions represent an important step toward the legal guarantee of access to emergency care for all people, further attention must be paid to the impact of such laws and regulation on the accessibility of emergency care and its related reduction of death and disability globally.

Governing access to emergency care in Africa.

Emergency care not only has the potential to address a large portion of death and disability in low- and middle-income countries, it is also essential to achieving the current Universal Health Coverage agenda and fulfilling the universal human right to the highest attainable standard of health. One of six health system building blocks, governance is often neglected but nonetheless essential for guaranteeing access and strengthening emergency care systems in Africa. In this paper, we highlight key components of governance that are necessary to guaranteeing access to emergency care, describe current examples of emergency care accessibility laws and regulation in various African countries, and suggest priorities for measuring and evaluating the impact of legal guarantees for access to emergency care in Africa.

Considerations for service delivery for emergency care in low resource settings.

In a shift from the more traditional disease focused model of global health interventions, increasing attention is now being placed on the importance of strengthening healthcare systems as a key component for achieving improved health outcomes. As emergency care systems continue to develop and strengthen around the world, the concept of service delivery provides one way to assess how well these systems are functioning. By focusing on service delivery, a system can be evaluated based on its ability to provide patients with access to the high-quality emergency care that they deserve. While the concept of service delivery is commonly used to evaluate the effectiveness of care in high-resource settings, its use in low resource settings has previously been limited due to challenges in operationalizing the concept in a context appropriate way. This article will begin by discussing the concept of service delivery as it specifically applies to emergency care systems and then discuss some of the challenges in defining and assessing this concept in low resource settings. The article will then discuss several new tools that have been developed to specifically address ways to evaluate emergency care service delivery in low-resource settings that can be used to inform future systems strengthening activities.

Emergency department management of traumatic brain injuries: A resource tiered review.

INTRODUCTION: Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20-30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. OBJECTIVES: Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. METHODS: A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. KEY RECOMMENDATIONS: Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

Developing emergency care systems: a human rights-based approach.

The delivery of emergency care is an effective strategy to reduce the global burden of disease. Emergency care cross cuts traditional disease-focused disciplines to manage a wide range of the acute illnesses and injuries that contribute substantially to death and disability, particularly in low- and middle-income countries. While the universal health coverage (UHC) movement is gaining support, and human rights and health systems are integral to UCH, few concrete discussions on the human right to emergency care have been taken place to date. Furthermore, no rights-based approach to developing emergency care systems has been proposed. In this article, we explore key components of the right to health (that is, availability, accessibility, acceptability and quality of health facilities, goods and services) as they relate to emergency care systems. We propose the use of a rights-based framework for the fulfilment of core obligations of the right to health and the progressive realization of emergency care in all countries.

La prestation de soins d'urgence constitue une stratégie efficace pour réduire la charge mondiale de morbidité. Les soins d'urgence recoupent les disciplines traditionnelles centrées sur les maladies pour prendre en charge de nombreuses blessures et affections aiguës qui contribuent sensiblement aux décès et aux handicaps, en particulier dans les pays à revenu faible et intermédiaire. Alors que le mouvement pour la couverture sanitaire universelle prend de l'ampleur et que les droits de l'homme et les systèmes de santé en font partie intégrante, peu de discussions concrètes sur le droit à des soins d'urgence ont eu lieu à ce jour. En outre, aucune démarche fondée sur les droits et visant à développer des systèmes de soins d'urgence n'a été proposée. Dans cet article, nous nous intéressons aux composantes clés du droit à la santé (à savoir la disponibilité, l'accessibilité, l'acceptabilité et la qualité des établissements, des produits et des services de soins) pour ce qui est des systèmes de soins d'urgence. Nous proposons d'utiliser un cadre fondé sur les droits pour l'exécution des obligations essentielles du droit à la santé et la mise en place progressive de soins d'urgence dans tous les pays.

La prestación de atención de emergencia es una estrategia eficaz para reducir la carga mundial de morbilidad. La atención de emergencia trasciende las disciplinas tradicionales centradas en las enfermedades para tratar una amplia gama de enfermedades y lesiones agudas que contribuyen sustancialmente a la muerte y la discapacidad, en particular en los países de ingresos bajos y medianos. Si bien el movimiento de la cobertura sanitaria universal (CSU) está ganando apoyo, y los derechos humanos y los sistemas de salud son parte integral de la CSU, hasta la fecha se han llevado a cabo pocas discusiones concretas sobre el derecho humano a la atención de emergencia. Además, no se ha propuesto un enfoque basado en los derechos para desarrollar sistemas de atención de emergencia. En este artículo exploramos los componentes clave del derecho a la salud (es decir, disponibilidad, accesibilidad, aceptabilidad y calidad de las instalaciones, bienes y servicios sanitarios) en relación con los sistemas de atención de emergencia. Proponemos el uso de un marco basado en los derechos para el cumplimiento de las obligaciones básicas del derecho a la salud y la realización progresiva de la atención de emergencia en todos los países.

Advancing research on the economic value of emergency care.

Emergency care and the emergency care system encompass an array of time-sensitive interventions to address acute illness and injury. Research has begun to clarify the enormous economic burden of acute disease, particularly in low-income and middle-income countries, but little is known about the cost-effectiveness of emergency care interventions and the performance of health financing mechanisms to protect populations against catastrophic health expenditures. We summarise existing knowledge on the economic value of emergency care in low resource settings, including interventions indicated to be highly cost-effective, linkages between emergency care financing and universal health coverage, and priority areas for future research.

Fifteen years of emergency medicine literature in Africa: A scoping review.

INTRODUCTION: Emergency medicine (EM) throughout Africa exists in various stages of development. The number and types of scientific EM literature can serve as a proxy indicator of EM regional development and activity. The goal of this scoping review is a preliminary assessment of potential size and scope of available African EM literature published over 15 years. METHODS: We searched five indexed international databases as well as non-indexed grey literature from 1999-2014 using key search terms including "Africa", "emergency medicine", "emergency medical services", and "disaster." Two trained physician reviewers independently assessed whether each article met one or more of five inclusion criteria, and discordant results were adjudicated by a senior reviewer. Articles were categorised by subject and country of origin. Publication number per country was normalised by 1,000,000 population. RESULTS: Of 6091 identified articles, 633 (10.4%) were included. African publications increased 10-fold from 1999 to 2013 (9 to 94 articles, respectively). Western Africa had the highest number (212, 33.5%) per region. South Africa had the largest number of articles per country (171, 27.0%) followed by Nigeria, Kenya, and Ghana. 537 (84.8%) articles pertained to facility-based EM, 188 (29.7%) to out-of-hospital emergency medicine, and 109 (17.2%) to disaster medicine. Predominant content areas were epidemiology (374, 59.1%), EM systems (321, 50.7%) and clinical care (262, 41.4%). The most common study design was observational (479, 75.7%), with only 28 (4.4%) interventional studies. All-comers (382, 59.9%) and children (91, 14.1%) were the most commonly studied patient populations. Undifferentiated (313, 49.4%) and traumatic (180, 28.4%) complaints were most common. CONCLUSION: Our review revealed a considerable increase in the growth of African EM literature from 1999 to 2014. Overwhelmingly, articles were observational, studied all-comers, and focused on undifferentiated complaints. The articles discovered in this scoping review are reflective of the relatively immature and growing state of African EM.

Adherence to Universal Travel Screening in the Emergency Department During Epidemic Ebola Virus Disease.

BACKGROUND: During the 2014 West African Ebola Virus Disease (EVD) outbreak, the U.S. Centers for Disease Control and Prevention recommended that all emergency department (ED) patients undergo travel screening for risk factors of importing EVD. OBJECTIVES: We sought to determine the overall adherence rate to the recommended travel screening protocol and to identify factors associated with nonadherence to the protocol. METHODS: We conducted a multicenter, retrospective analysis of adherence to the travel screening program in an academic hospital and three affiliated community hospitals. A regression model identified patient and hospital factors associated with nonadherence. RESULTS: Of the 147,062 patients included for analysis, 93.7% (n = 137,834) had travel screenings completed. We identified several characteristics of patients that were most likely to be missed by the screening protocol-patients with low English proficiency, patients who arrive via ambulance or helicopter, and patients with more severe illness or injury based on initial triage acuity. CONCLUSIONS: These findings should be used to improve adherence to the travel screening protocol for future emerging infectious disease threats.

Free Open Access Medical Education (FOAM) in Emergency Medicine: The Global Distribution of Users in 2016.

INTRODUCTION: Free open-access medical education (FOAM) is a collection of interactive online medical education resources-free and accessible to students, physicians and other learners. This novel approach to medical education has the potential to reach learners across the globe; however, the extent of its global uptake is unknown. METHODS: This descriptive report evaluates the 2016 web analytics data from a convenience sample of FOAM blogs and websites with a focus on emergency medicine (EM) and critical care. The number of times a site was accessed, or "sessions", was categorized by country of access, cross-referenced with World Bank data for population and income level, and then analyzed using simple descriptive statistics and geographic mapping. RESULTS: We analyzed 12 FOAM blogs published from six countries, with a total reported volume of approximately 18.7 million sessions worldwide in 2016. High-income countries accounted for 73.7% of population-weighted FOAM blog and website sessions in 2016, while upper-middle income countries, lower-middle income countries and low-income countries accounted for 17.5%, 8.5% and 0.3%, respectively. CONCLUSION: FOAM, while largely used in high-income countries, is used in low- and middle-income countries as well. The potential to provide free, online training resources for EM in places where formal training is limited is significant and thus is prime for further investigation.

Emergency Physicians as Good Samaritans: Survey of Frequency, Locations, Supplies and Medications.

INTRODUCTION: Little is known about the frequency and locations in which emergency physicians (EPs) are bystanders to an accident or emergency; equally uncertain is which contents of an "emergency kit" may be useful during such events. The aim of this study was to describe the frequency and locations of Good Samaritan acts by EPs and also determine which emergency kit supplies and medications were most commonly used by Good Samaritans. METHODS: We conducted an electronic survey among a convenience sample of EPs in Colorado. RESULTS: Respondents reported a median frequency of 2.0 Good Samaritan acts per five years of practice, with the most common locations being sports and entertainment events (25%), road traffic accidents (21%), and wilderness settings (19%). Of those who had acted as Good Samaritans, 86% reported that at least one supply would have been useful during the most recent event, and 66% reported at least one medication would have been useful. The most useful supplies were gloves (54%), dressings (34%), and a stethoscope (20%), while the most useful medications were oxygen (19%), intravenous fluids (17%), and epinephrine (14%). CONCLUSION: The majority of EPs can expect to provide Good Samaritan care during their careers and would be better prepared by carrying a kit with common supplies and medications where they are most likely to use them.