Consensus-based quality standards for emergency departments in Palestine.

OBJECTIVES: The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine. METHODS: The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS. FINDINGS: We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes. CONCLUSION: This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges.

Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage.

Objectives: Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods: After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results: Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion: There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence: Not applicable.

Implementation and evaluation of a pilot WHO community first aid responder training in Kinshasa, DR Congo: A mixed method study.

Introduction: Prehospital care in many low- and middle-income countries is underdeveloped and needs strengthening for improved outcomes. Where formal prehospital care systems are under development, integration of a layperson first responder programme may help improve access for those in need. The World Health Organization recently developed the Community First Aid Responder (CFAR) learning program in support of this system, providing that it may require adaptation to be contextually suitable and sustainably implemented at country level. This study assesses a pilot WHO CFAR course in Kinshasa, Democratic Republic of Congo, to inform future rollouts and related research. Methods: We conducted a 3-day in-person pilot CFAR training with 42 purposively selected community health workers. Data collection involved quantitative and qualitative phases. The first consisted of structured pre- and post-training surveys, and a course evaluation by participants. The second consisted of two focus group discussions involving purposively selected community health workers in one group, and a convenience sample of course instructors and organisers in the other. Perceptions regarding course content, perceived knowledge acquisition and self-confidence gain were analysed using descriptive statistics for the quantitative data and content analysis for qualitative data. Results: Course participants were predominantly male (76.3 %) with a median age of 42 years and most (80.5 %) had no prior first aid training. Most were satisfied that the learning objectives were reached, the logistics were adequate, and that the content and teaching language were appropriately tailored to local context. The majority (94.7 %) found the 3-day duration insufficient. There was a significant self-confidence gain regarding first aid skills (average 17.9 % in pre- to 95.3 % in post-training, p < 0.001). Favourable opinions on the course structure, content, logistics and teaching methods were noted. Conclusion: A CFAR course pilot was successfully conducted in Kinshasa. The course is appropriate for context and well received by participants. It can form a key component of developing prehospital care systems in resource-constrained settings.

The variables predictive of ambulance non-conveyance of patients in the Western Cape, South Africa.

Introduction: Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital. Methods: A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital. Results: A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55-5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60-2.37; p<0.01).Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36-15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10-3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51-2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54-2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21-1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11-6.41; p<0.01)). Conclusion: This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study.

INTRODUCTION: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study.

BACKGROUND: Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa. METHODS: An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days. RESULTS: Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage. CONCLUSION: No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.

Interprofessional sense-making in the emergency department: A SenseMaker study.

BACKGROUND: Emergency Departments serve as a main entry point for patients into hospitals, and the team, the core of which is formed by doctors and nurses needs to make sense of and respond to the constant flux of information. This requires sense-making, communication, and collaborative operational decision-making. The study's main aim was to explore how collective, interprofessional sense-making occurs in the emergency department. Collective sense-making is deemed a precursor for adaptive capability, which, in turn, promotes coping in a dynamically changing environment. METHOD: Doctors and nurses working in five large state emergency departments in Cape Town, South Africa, were invited to participate. Using the SenseMaker® tool, a total of 84 stories were captured over eight weeks between June and August 2018. Doctors and nurses were equally represented. Once participants shared their stories, they self-analysed these stories within a specially designed framework. The stories and self-codified data were analysed separately. Each self-codified data point was plotted in R-studio and inspected for patterns, after which the patterns were further explored. The stories were analysed using content analysis. The SenseMaker® software allows switching between quantitative (signifier) and qualitative (descriptive story) data during interpretation, enabling more deeply nuanced analyses. RESULTS: The results focused on four aspects of sense-making, namely views on the availability of information, the consequences of decisions (actions), assumptions regarding appropriate action, and preferred communication methods. There was a noticeable difference in what doctors and nurses felt would constitute appropriate action. The nurses were more likely to act according to rules and policies, whereas the doctors were more likely to act according to the situation. More than half of the doctors indicated that they found it best to communicate informally, whereas the nurses indicated that formal communication worked best for them. CONCLUSION: This study was the first to explore the ED's interprofessional team's adaptive capability to respond to situations from a sense-making perspective. We found an operational disconnect between doctors and nurses caused by asymmetric information, disjointed decision-making approaches, differences in habitual communication styles, and a lack of shared feedback loops. By cultivating their varied sense-making experiences into one integrated operational foundation with stronger feedback loops, interprofessional teams' adaptive capability and operational effectiveness in Cape Town EDs can be improved.

Implementation and evaluation of a pilot WHO community first aid responder training in Kinshasa, DR Congo: A mixed method study

Introduction: Prehospital care in many low- and middle-income countries is underdeveloped and needs strengthening for improved outcomes. Where formal prehospital care systems are under development, integration of a layperson first responder programme may help improve access for those in need. The World Health Organization recently developed the Community First Aid Responder (CFAR) learning program in support of this system, providing that it may require adaptation to be contextually suitable and sustainably implemented at country level. This study assesses a pilot WHO CFAR course in Kinshasa, Democratic Republic of Congo, to inform future rollouts and related research. Methods: We conducted a 3-day in-person pilot CFAR training with 42 purposively selected community health workers. Data collection involved quantitative and qualitative phases. The first consisted of structured pre- and post-training surveys, and a course evaluation by participants. The second consisted of two focus group discussions involving purposively selected community health workers in one group, and a convenience sample of course instructors and organisers in the other. Perceptions regarding course content, perceived knowledge acquisition and self-confidence gain were analysed using descriptive statistics for the quantitative data and content analysis for qualitative data. Results: Course participants were predominantly male (76.3 %) with a median age of 42 years and most (80.5 %) had no prior first aid training. Most were satisfied that the learning objectives were reached, the logistics were adequate, and that the content and teaching language were appropriately tailored to local context. The majority (94.7 %) found the 3-day duration insufficient. There was a significant self-confidence gain regarding first aid skills (average 17.9 % in pre- to 95.3 % in post-training, p < 0.001). Favourable opinions on the course structure, content, logistics and teaching methods were noted. Conclusion: A CFAR course pilot was successfully conducted in Kinshasa. The course is appropriate for context and well received by participants. It can form a key component of developing prehospital care systems in resource-constrained settings.

Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda.

BACKGROUND: Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS: A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS: Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION: Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.

The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa.

BACKGROUND: Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the "Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)" study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa. METHODS: The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient's clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure). DISCUSSION: This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system. TRIAL REGISTRATION: Not applicable as this study is not a clinical trial.

Understanding people's experiences of extrication while being trapped in motor vehicles: a qualitative interview study.

OBJECTIVE: To explore patient's experience of entrapment and subsequent extrication following a motor vehicle collision and identify their priorities in optimising this experience. DESIGN: Semistructured interviews exploring the experience of entrapment and extrication conducted at least 6 weeks following the event. Thematic analysis of interviews. SETTING: Single air ambulance and spinal cord injury charity in the UK. PARTICIPANTS: 10 patients were recruited and consented; six air ambulance patients and two spinal cord injury charity patients attended the interview. 2 air ambulance patients declined to participate following consent due to the perceived potential for psychological sequelae. RESULTS: The main theme across all participants was that of the importance of communication; successful communication to the trapped patient resulted in a sense of well-being and where communication failures occurred this led to distress. The data generated three key subthemes: 'on-scene communication', 'physical needs' and 'emotional needs'. Specific practices were identified that were of use to patients during entrapment and extrication. CONCLUSIONS: Extrication experience was improved by positive communication, companionship, explanations and planned postincident follow-up. Extrication experience was negatively affected by failures in communication, loss of autonomy, unmanaged pain, delayed communication with remote family and onlooker use of social media. Recommendations which will support a positive patient-centred extrication experience are the presence of an 'extrication buddy', the use of clear and accessible language, appropriate reassurance in relation to co-occupants, a supportive approach to communication with family and friends, the minimisation of onlooker photo/videography and the provision of planned (non-clinical) follow-up.

Pre-course online cases for the world health organization's basic emergency care course in Uganda: A mixed methods analysis.

Introduction: The Ministry of Health - Uganda implemented the World Health Organization's Basic Emergency Care course (BEC) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants' knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases. Methods: Multiple Choice Questions (MCQs) and Likert-scale surveys assessed 137 providers' knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers' perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions. Results: Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p < 0.001). The intervention group scored significantly higher on the pre-test MCQ than controls (p = 0.004) and insignificantly higher at all other times (p > 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage. Conclusion: Basic emergency care courses for low-resource settings can increase frontline providers' long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.

Prolonged casualty care: Extrapolating civilian data to the military context.

BACKGROUND: Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource limitations, and system configuration to US military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations. METHODS: We conducted a 6-month analysis of an ongoing, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape (Epidemiology and Outcomes of Prolonged Trauma Care [EpiC]). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using χ 2 and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models. RESULTS: Of 995 patients, 146 experienced PCC. The PCC group, compared with non-PCC, were more critically injured (66% vs. 51%), received more critical interventions (36% vs. 29%), and had a greater proportionate mortality (5% vs. 3%), longer hospital stays (3 vs. 1 day), and higher Sequential Organ Failure Assessment scores (5 vs. 3). The odds of 7-day mortality and a Sequential Organ Failure Assessment score of ≥5 were 1.6 (odds ratio, 1.59; 95% confidence interval, 0.68-3.74) and 3.6 (odds ratio, 3.69; 95% confidence interval, 2.11-6.42) times higher, respectively, in PCC versus non-PCC patients. CONCLUSION: The EpiC study enrolled critically injured patients with PCC who received resuscitative interventions. Prolonged casualty care patients had worse outcomes than non-PCC. The EpiC study will be a useful platform to provide ongoing data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care. LEVEL OF EVIDENCE: Therapeutic/care management; Level IV.

Prehospital triage tools across the world: a scoping review of the published literature.

BACKGROUND: Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. METHODS: A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. RESULTS: Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools' ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools' diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools' prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. CONCLUSIONS: The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear 'gold-standard' singular prehospital triage tool for acute undifferentiated patients. TRIAL REGISTRATION: Not applicable.

Out-of-hospital cardiac arrest in Africa: a scoping review.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is well studied in high-income countries, and research has encouraged the implementation of policy to increase survival rates. On the other hand, comprehensive research on OHCA in Africa is sparse, despite the higher incidence of risk factors. In this vein, structural barriers to OHCA care in Africa must be fully recognised and understood before similar improvements in outcome may be made. The aim of this study was to describe and summarise the body of literature related to OHCA in Africa. METHODS AND ANALYSIS: Using an a priori developed search strategy, electronic searches were performed in Medline via Pubmed, Web of Science, Scopus and Google Scholar databases to identify articles published in English between 2000 and 2020 relevant to OHCA in Africa. Titles, abstract and full text were reviewed by two reviewers, with discrepancies handled by an independent reviewer. A summary of the main themes contained in the literature was developed using descriptive analysis on eligible articles. RESULTS: A total of 1200 articles were identified. In the screening process, 785 articles were excluded based on title, and a further 127 were excluded following abstract review. During full-text review to determine eligibility, 80 articles were excluded and one was added following references review. A total of 19 articles met the inclusion criteria. During analysis, the following three themes were found: epidemiology and underlying causes for OHCA, first aid training and bystander action, and Emergency Medical Services (EMS) resuscitation and training. CONCLUSIONS: In order to begin addressing OHCA in Africa, representative research with standardised reporting that complies to data standards is required to understand the full, context-specific picture. Policies and research may then target underlying conditions, improvements in bystander and EMS training, and system improvements that are contextually relevant and ultimately result in better outcomes for OHCA victims.

Clinical impact of a prehospital trauma shock bundle of care in South Africa.

INTRODUCTION: Patients experiencing traumatic shock are at a higher risk for death and complications. We previously designed a bundle of emergency medical services traumatic shock care ("EMS-TruShoC") for prehospital providers in resource-limited settings. We assess how EMS-TruShoC changes clinical outcomes of critically injured prehospital patients. METHODS: This is a quasi-experimental educational implementation of a simplified bundle of care using a pre-post design with a control group. The intervention was delivered to EMS providers in Western Cape, South Africa. Delta shock index (heart rate divided by systolic blood pressure, reported as change from the scene to facility arrival) from the 13 months preceding intervention were compared to the 13 months post-implementation. A difference-in-differences analysis examined the difference in mean shock index change between the groups. RESULTS: Data were collected from 198 providers who treated 770 severe trauma patients. The patient groups had similar demographic and clinical characteristics at baseline. Over all time-points, both groups had an increase in mean delta shock index (worsening shock), with the largest difference occurring 4-months post-implementation (0.047 change in control arm, 0.004 change in intervention arm; -0.043 difference-in-differences, P = 0.27). In pre-specified subgroup analyses, there was a statistically significant improvement in delta shock index in the intervention arm in patients with penetrating trauma cared for by basic providers immediately post-implementation (-0.372 difference-in-differences, P = 0.02). DISCUSSION: Overall, there was no significant difference in delta shock index between the EMS-TruShoC intervention versus control groups. However, significant improvement in shock index in one subgroup suggests the intervention may be more likely to benefit penetrating trauma patients and basic providers.

Measuring quality of pre-hospital traumatic shock care-development and validation of an instrument for resource-limited settings.

BACKGROUND AND AIMS: Improving the quality of pre-hospital traumatic shock care, especially in low- and middle-income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high-quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre-hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource-limited, pre-hospital emergency care setting. METHODS: Traumatic shock was selected as the tracer condition. The pre-hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot-testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter- and intra-rater agreement were calculated. RESULTS: The final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter- and intra-rater reliability when used by trained pre-hospital provider users in South Africa. Pre-hospital provider user feedback indicates the tool is easy to learn and quick to use. CONCLUSION: We created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre-hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource-limited care settings.

Potential solutions for screening, triage, and severity scoring of suspected COVID-19 positive patients in low-resource settings: a scoping review.

OBJECTIVES: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS. DESIGN: A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. PARTICIPANT: The initial search strategy yielded 15 232 articles; 124 met inclusion criteria. RESULTS: Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries. CONCLUSIONS: This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic.

Essential Emergency and Critical Care: a consensus among global clinical experts.

BACKGROUND: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records.

OBJECTIVES: While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa. DESIGN: Observational study with a retrospective descriptive design. SETTING: Cape Town metropole, Western Cape province, South Africa. PARTICIPANTS: All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described. OUTCOME MEASURES: Description of patients with OHCA in terms of demographics, treatment and short-term outcome. RESULTS: A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene. CONCLUSION: To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.