Evaluating the prerequisites for adapting a paediatric nighttime telemedicine and medication delivery service to a setting with high malarial burden: A cross-sectional pre-implementation study.

OBJECTIVE: We sought to evaluate the prerequisites (demand, interest, feasibility) for adapting a paediatric nighttime telemedicine and medication delivery service (TMDS) to Ghana. METHODS: A cross-sectional survey of households and associated healthcare providers was conducted in urban and rural Ghana. Households were identified through randomised geospatial sampling; households with at least one child <10 years were enrolled. Household surveys collected information relating to demographics, household resources, standardised case scenarios, recent paediatric health events, satisfaction with healthcare access, and interest in TMDS intervention models. Providers were identified by households and enrolled. Provider surveys collected provider type, hours of operation, services, and opinions of a TMDS model. RESULTS: A total of 511 (263 urban, 248 rural) households and 18 providers (10 urban, 8 rural) were surveyed. A total of 262 health events involving children <10 years were reported, of which 47% occurred at night. Care was sought for >70% of health events presenting at night; however, care-seeking was delayed until morning or later for >75% of these events; 54% of households expressed dissatisfaction with their current access to paediatric care at night; 99% of households expressed that a nighttime TMDS service for children would be directly useful to their families. Correspondingly, 17 of 18 providers stated that a TMDS was needed in their community; >99% of households had access to a cellular phone. All households expressed willingness to use their phones to call a TMDS and allow a TMDS provider into their homes at night. Willingness to pay and provider-recommended price points varied by setting. CONCLUSIONS: Prerequisites for adapting a TMDS to Ghana were met. A nighttime paediatric TMDS service was found to be needed, appealing, and feasible in Ghana. These data motivate the adaptation of a TMDS to urban and rural Ghana.

The state of emergency medical technician education in Ghana.

OBJECTIVE: The National Ambulance Service (NAS) provides emergency medical services throughout Ghana and trains emergency medical technicians (EMTs) at the NAS Prehospital Emergency Care Training School (PECTS). Currently the majority of EMT training occurs primarily in a traditional didactic format. Students and faculty were interviewed to better understand their views of the current curriculum. Additionally, any barriers to integration of simulation-based learning were assessed. Following the interviews, the faculty was trained to conduct obstetric and neonatal simulations. The faculty was then observed introducing the simulations to the EMT students. METHODS: A standardized list of questions developed in consultation with an education expert was used to elicit student and faculty expression of opinion. Interviews were conducted in-person in small group settings. Training sessions were conducted in-person in large group settings. RESULTS: Students and faculty alike expressed pride in their work and 14/25 groups felt that teaching efforts were high. However, students verbalized concern involving their lack of rest (12/18) and the high volume of lectures per day (11/18). Both students and faculty felt limited by the lack of simulation tools (17/25), library resources (14/25), internet access (17/25), and infrastructure (20/25). All groups felt favorably towards the integration of simulation-based learning (25/25). CONCLUSION: The faculty and students of PECTS support the transition from a curriculum based on traditional didactic learning to one based on simulation learning.

Combination of biphasic transmittance waveform with blood procalcitonin levels for diagnosis of sepsis in acutely ill patients.

OBJECTIVES: To assess the diagnostic utility of combining measurement of blood procalcitonin (PCT) concentrations with the presence of a biphasic transmittance waveform (BPW) from the activated partial thromboplastin time (aPTT) to identify sepsis in critically ill patients. DESIGN: Prospective observational study. SETTING: Thirty-one-bed university hospital department of medico-surgical intensive care. PATIENTS: Two hundred consecutive adult patients admitted to the department during a 3-month period. MEASUREMENTS AND MAIN RESULTS: aPTT waveform analysis was performed on admission and daily throughout the intensive care unit (ICU) stay. Receiver operating characteristic curves were created to determine the best threshold values of BPW and PCT for prediction of sepsis. Of the 200 patients, 63 (32%) had sepsis during the ICU stay; 29 (15%) patients were diagnosed with sepsis at admission. Using a threshold value of BPW slope_1 = -0.075%T/sec, 37 patients (19%) had a BPW at ICU admission and 84 (42%) at some time during the ICU stay. At this threshold, 23 of the patients (62%) with a BPW at admission and 51 (61%) with a BPW during the ICU stay were diagnosed with sepsis. Using a cut-off value of 1 ng/ml, 60 patients (30%) had abnormal PCT at admission, and 86 during the ICU stay. At this threshold, 24 of the patients (40%) with abnormal PCT at admission and 52 (60%) with abnormal PCT during the ICU stay were diagnosed with sepsis. Thirty patients had a BPW and an abnormal PCT, and 23 (77%) of these had sepsis. Of the other 170 patients, only six patients (4%) had sepsis. Hence, the sensitivity of the combination of BPW and PCT at admission was 79% and specificity 96%; the negative predictive value was 96%. CONCLUSION: aPTT waveform analysis is an easy and rapid method for identification of sepsis; its combination with PCT increases its specificity.

Barriers to Accessing Emergency Medical Services in Accra, Ghana: Development of a Survey Instrument and Initial Application in Ghana.

BACKGROUND: Emergency medical services (EMS) systems provide professional prehospital emergency medical care and transportation to help improve outcomes from emergency conditions. Ghana's national ambulance service has relatively low public utilization in comparison with the large burden of acute disease. METHODS: A survey instrument was developed using Pechansky and Thomas's model of access covering 5 dimensions of availability, accessibility, accommodation, affordability, and acceptability. The instrument was used in a cross-sectional survey in 2013 in Accra, Ghana; eligible participants were those 18 years and older who spoke English, French, or Twi. Although the analysis was mainly descriptive, logistic regression was used to identify factors associated with reported intention to call for an ambulance in the case of a medical emergency. RESULTS: 468 participants completed surveys, with a response rate of 78.4%. Few (4.5%) respondents had ever used an ambulance in prior emergency situations. A substantial proportion (43.8%) knew about the public access medical emergency telephone number, but of those only 37.1% knew it was a toll-free call. Most (54.7%) respondents believed EMTs offered high-quality care, but 78.0% believed taxis were faster than ambulances and 69.2% thought the number of ambulances in Accra insufficient. Many (23.4%) thought using ambulances to transport corpses would be appropriate. In two hypothetical emergency scenarios, respondents most commonly reported taxis as the preferred transportation (63.6% if a family member were burned in a house fire, 64.7% if a pedestrian were struck by a vehicle). About 1 in 5 respondents said they would call an ambulance in either scenario (20.7% if a family member were burned in a house fire, 23.3% if a pedestrian were struck by a vehicle) while 15.5% and 10.2%, respectively, would use any available vehicle. Those aged 18-35 years were more likely than older respondents to prefer an ambulance (odds ratio [OR], 2.27; confidence interval [CI], 1.47 to 3.68), as were those with prior ambulance experience (OR, 1.75; CI, 0.98 to 3.09) (compared with those with no prior experience) and those who believed ambulances were safer than taxis (OR, 2.17; CI, 1.1 to 4.2) (compared with those who did not hold such beliefs). CONCLUSIONS: Perceptions of public ambulance services in Accra, Ghana, are generally favorable, although use is low. Public health education to improve awareness of the toll-free medical emergency number and about appropriate use of ambulances while simultaneously improving the capacity of ambulance agencies to receive increased caseload could improve use of the EMS system.

The state of emergency medical technician education in Ghana

Objective: The National Ambulance Service (NAS) provides emergency medical services throughout Ghana and trains emergency medical technicians (EMTs) at the NAS Prehospital Emergency Care Training School (PECTS). Currently the majority of EMT training occurs primarily in a traditional didactic format. Students and faculty were interviewed to better understand their views of the current curriculum. Additionally, any barriers to integration of simulation-based learning were assessed. Following the interviews, the faculty was trained to conduct obstetric and neonatal simulations. The faculty was then observed introducing the simulations to the EMT students. Methods: A standardized list of questions developed in consultation with an education expert was used to elicit student and faculty expression of opinion. Interviews were conducted in-person in small group settings. Training sessions were conducted in-person in large group settings. Results: Students and faculty alike expressed pride in their work and 14/25 groups felt that teaching efforts were high. However, students verbalized concern involving their lack of rest (12/18) and the high volume of lectures per day (11/18). Both students and faculty felt limited by the lack of simulation tools (17/25), library resources (14/25), internet access (17/25), and infrastructure (20/25). All groups felt favorably towards the integration of simulation-based learning (25/25). Conclusion: The faculty and students of PECTS support the transition from a curriculum based on traditional didactic learning to one based on simulation learning

Serum levels of C-reactive protein and procalcitonin in critically ill patients with cirrhosis of the liver.

Concentrations of C-reactive protein (CRP) and procalcitonin (PCT) have been suggested as markers of infection. The liver is believed to be a key source of CRP and PCT. For this reason we assessed the predictive value of these markers in patients with hepatic cirrhosis in a 31-bed university-hospital department of intensive care. Demographic, clinical, laboratory, and microbiologic data were collected prospectively over 9 months. Of 864 patients included in the study, 79 (9%) had hepatic cirrhosis. Patients with cirrhosis were more likely to have a medical than a surgical admission diagnosis (67 vs 47%, P = .03). They also had a higher rate of infection (48 vs 30%, P = .03) and higher mortality (44 vs 17%, P = .01) than did patients without cirrhosis. We detected no differences in CRP and PCT concentrations among patients with cirrhosis and different disease severity as assessed on the basis of Child-Pugh score. The serum CRP concentration (admission 11.2 +/- 4.6 vs 13.0 +/- 5.8, maximum 13.9 +/- 6.4 vs 18.8 +/- 7.3 mg/dL) and PCT (admission 1.3 +/- 0.9 vs 2.0 +/- 1.4, maximum 3.3 +/- 1.8 vs 3.4 +/- 2.1 ng/mL) were slightly lower in infected patients with cirrhosis than in infected patients without cirrhosis, but the differences were not statistically significant. Although the liver is considered the main source of CRP and a source of PCT, serum levels of these acute-phase proteins are not significantly lower in patients with cirrhosis than in other patients. Moreover, the predictive power of CRP and PCT for infection was similar for patients with and without cirrhosis.