Acute care needs in a rural Sub-Saharan African Emergency Centre: A retrospective analysis

AbstractIntroductionIn June of 2008, Karoli Lwanga (“Nyakibale”) Hospital and Global Emergency Care Collaborative (GECC) opened the first functional Emergency Centre (EC) in rural Uganda. GECC is developing a training programme for a new cadre of midlevel Emergency Care Practitioners (ECPs), to increase access to quality emergency care. In order to determine the skills and resources needed, the unique practice demographics and the feasibility of treating patients in this setting must be understood.MethodsA descriptive cross-sectional analysis of the first 500 consecutive patient visits in the EC’s patient care log was reviewed. Data on demographics, procedures performed, laboratory testing, bedside ultrasounds (USs) performed, radiographs (XRs) ordered, diagnoses, condition upon discharge and disposition were collated. Descriptive statistics were performed.ResultsOf the first 500 patient visits, there were 275 (55%) male visits and 132 (26.4%) visits for children under five. Procedures were performed in 367 (73.4%) patients. Laboratory testing, XRs and USs were performed in 188 (37.6%), 99 (19.8%) and 45 (7%) patients, respectively. Infectious diseases were diagnosed in 217 (43.4%) patients; traumatic injuries in 140 (28%) patients. Only one patient expired in the ED, and 401 (80.2%) were in good condition after treatment. One person was transferred to another hospital. After treatment, 180 (36%) patients were discharged home. Only five (1.0%) patients went directly to the operating theatre.ConclusionsThis pilot study describes the patient population, resource and training needs of a rural Emergency Centre in SSA. It demonstrates that acute care providers will be required to evaluate a wide variety of patient complaints, effectively utilise laboratory and radiologic testing, and perform numerous focused treatments and therapies. Specialised training programmes, such as GECC’s ECP programme, are needed to create providers able to provide high quality, lifesaving care

Alcohol-related hypoglycemia in rural Uganda: socioeconomic and physiologic contrasts

Hypoglycemia is a rare but important complication seen in patients who present with alcohol intoxication. In a study by Marks and Teale, less than one percent of people with alcohol intoxication who presented to an American emergency department were hypoglycemic [1]. It is even more rare to see an intoxicated patient, who had been eating appropriately prior to or during the intoxication, present in a hypoglycemic coma. However, our analysis of the first 500 patients seen in a newly opened five-bed Emergency Department (ED) at Nyakibale Karoli Lwanga Hospital in rural southwestern Uganda, revealed multiple intoxicated patients who presented in hypoglycemic coma within hours of eating a full meal. Three of these cases are summarized and discussed below

Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda.

BACKGROUND: A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care. METHODS: A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ(2) tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality. RESULTS: Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were severely ill. The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47). CONCLUSIONS: Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients

World Health Assembly Resolution 60.22. [corrected].

The World Health Assembly 2007 Resolution 60.22 tasked the global health community to address the lack of emergency care in low- and middle-income countries. Little progress has yet been made in integrating emergency care into most low- and middle-income-country health systems. At a rural Ugandan district hospital, however, a collaborative between a nongovernmental organization and local and national stakeholders has implemented an innovative emergency care training program. To our knowledge, this is the first description of using task shifting in general hospital-based emergency care through creation of a new nonphysician clinician cadre, the emergency care practitioner. The program provides an example of how emergency care can be practically implemented in low-resource settings in which physician numbers are limited. The Ministry of Health is directing its integration into the national health care system as a component of a larger ongoing effort to develop a tiered emergency care system (out-of-hospital, clinic- and hospital-based provider and physician trainings) in Uganda. This tiered emergency care system is an example of a horizontal health system advancement that offers a potentially attractive solution to meet the mandate of World Health Assembly 60.22 by providing inexpensive educational interventions that can make emergency care truly accessible to the rural and urban communities of low- and middle-income countries

Task shifting: Meeting the human resources needs for acute and emergency care in Africa

The enormous shortage of health workers in sub-Saharan Africa (SSA) is a major contributor to the unacceptably high rates of morbidity and mortality in the region. This is especially true for patients whose illnesses and injuries require time-sensitive interventions. To address the crisis, a number of countries have utilized “task-shifting” in various health disciplines where they call upon other cadres, often nurses, to assume new roles and responsibilities that are not traditionally within their scope of practice. This practice has been shown to increase access, to be cost-effective and of high-quality. A literature review was undertaken to better understand the implications of task-shifting on emergency medical care in Africa. This review demonstrates that, while task-shifting has been used effectively for specific emergency procedures in specialty fields such as obstetrics and surgery, to date there are no studies on the use of task-shifting to treat the acute, undifferentiated patient in SSA. Task shifting is a potential solution to help address the very limited access to emergency care across SSA, but requires further study to ensure effective implementation

What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda

Objectives To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients. Setting A single emergency department (ED) of a district-level hospital in rural Uganda. Participants 26 710 patient visits. Results Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. Conclusion This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.Open access journal.This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda.

OBJECTIVES: To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients. SETTING: A single emergency department (ED) of a district-level hospital in rural Uganda. PARTICIPANTS: 26 710 patient visits. RESULTS: Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. CONCLUSION: This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills

Mortality Related to Acute Illness and Injury in Rural Uganda: Task Shifting to Improve Outcomes

<div><p>Background</p><p>Due to the dual critical shortages of acute care <i>and</i> healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients.</p><p>Methods</p><p>Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department’s quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit.</p><p>Findings</p><p>Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives.</p><p>Interpretation</p><p>This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.</p></div

Comparison of Patient Visits with and without Follow-up.

<p>Comparison of Patient Visits with and without Follow-up.</p