Emergency medical services (EMS) training in Kenya: Findings and recommendations from an educational assessment

Background: Over the past twenty years, Kenya has been developing many important components of a prehospital emergency medical services (EMS) system. This is due to the ever-increasing demand for emergency medical care across the country. To better inform the next phase of this development, we undertook an assessment of the current state of EMS training in Kenya. Methods: A group of international and Kenyan experts with relevant EMS and educational expertise conducted an observational qualitative assessment of Kenyan EMS training institutions in 2016. Three assessment techniques were utilised: semi-structured interviews, document review, and structured observations. Recommendations were reached through a consensus process amongst the assessment team. Results: Key findings include: (i) No national or state-level policy exists that establishes levels of EMS providers or expected fund of knowledge and skills; (ii) Training institutions have independently created their own individual training standards; (iii) Training materials are not adapted for the local context; (iv) The foundation of basic anatomy and physiology education is weak; (v) Training does not focus on symptom- or syndrome-based complaints; (vi) Students had difficulty applying foundational classroom knowledge in simulations and clinical encounters; (vii) There is limited emphasis on complex critical thinking. Discussion: Standardisation of training is needed in Kenya, including clearly defined levels of providers and expected learning outcomes. A nationally standardised EMS provider scope of practice may also help focus EMS education. Instructors must reinforce basic anatomy and physiology amongst all trainees to establish a robust foundation, then layer on field experience before trainees receive advanced training. Training graduates should be EMS providers who approach patient care with high-order symptom- or syndrome-based critical thinking. While these recommendations are specific to the Kenyan EMS environment, they may have wider applicability to other developing EMS systems in resource-limited settings

Access to out-of-hospital emergency care in Africa : consensus conference recommendations

Abstract: Out-of-hospital emergency care (OHEC) should be accessible to all who require it. However available data suggests that there are a number of barriers to such access in Africa, mainly centred around challenges in public knowledge, perception and appropriate utilisation of OHEC. Having reached consensus in 2013 on a two-tier system of African OHEC, the African Federation for Emergency Medicine (AFEM) OHEC Group sought to gain further consensus on the narrower subject of access to OHEC in Africa. The objective of this paper is to report the outputs and statements arising from the AFEM OHEC access consensus meeting, held in Cape Town, South Africa in April 2015. The discussion was structured around six dimensions of access to care (awareness, availability, accessibility, accommodation, affordability and acceptability) and tackled both Tier-1 (community first responder) and Tier-2 (formal prehospital services and Emergency Medical Services) OHEC systems. In Tier-1 systems, the role of community involvement and support was emphasised, along with the importance of a first responder system acceptable to the community in which it is embedded in order to optimise access. In Tier-2 systems, the consensus group highlighted the primacy of a single toll-free emergency number , matching of Emergency Medical Services resource demand and availability through appropriate planning and the cost-free nature of Tier-2 emergency care, among other factors that impact accessibility. Much work is still needed in prioritising the steps and clarifying the tools and metrics that would enable the ideal of optimal access to OHEC in Africa

Utilisation of whatsapp for emergency medical services in Garissa, Kenya.

Garissa county, Kenya is a geographically large county with a mobile pastoralist population that has developed a method for emergency medical services (EMS) coordination using the WhatsApp communication platform. This work was based on a site visit, to better understand and describe the current operations, strengths, and weaknesses of the EMS communication system in Garissa. The use of WhatsApp in Garissa county seems to work well in the local context and has the potential to serve as a cost-effective solution for other EMS systems in Kenya, Africa, and other LMICs

Epidemiology of ambulance utilized patients in Addis Ababa, Ethiopia

Background Well organized and appropriately utilized pre-hospital emergency services play a critical role in augmenting emergency care systems. The primary objective of this study was to understand the demographic and clinical profile of patients who used ambulances in Addis Ababa. The secondary objectives were to assess ambulance response time, transport time and reasons for referral amongst inter-facility transported patients in Addis Ababa. Methods The study was designed as a cross-sectional retrospective chart review of ambulance transported patients using ambulance station records from Addis Ababa Fire and Emergency Prevention and Control Authority. With IRB approval, simple random sampling and manual review of six months of clinical records was performed. Data were collected by trained data collectors and descriptive analysis was done using SPSS version 20. Results Female patients used ambulance services more often than males (female to male ratio of 3:1) and the mean age of the patients was 26 years. The most commonly transported age group was 16–30 years, followed by 31–50 years and neonatal patients (i.e. < 1 month). The majority of the patients had pregnancy related illnesses (n = 492, 61.4%), followed by general medical issues (n = 210, 26.2%) and injury secondary to trauma (n = 99, 12.3%). Most patients (n = 702, 87.6%) were transported for inter-facility transfers, while only 12.4% (n = 99) were primary responses (i.e. from the scene). Prolonged labor was the most common reason (n = 103, 23.4%) for inter-facility transfer of pregnant patients, followed by premature rupture of the amniotic membrane (n = 60, 13.6%). The mean dispatch to scene time interval was 10.1 min, and mean scene to facility time interval was 17.2 min. Conclusion Inter-facility transfers accounted for the largest proportion of ambulance utilization and dispatch in Addis Ababa. Ambulance transport time was twice as long compared to international recommendations of less than eight minutes for emergent transports. The most common reasons for ambulance dispatch were Obstetric. We recommend urgent action to decrease the transport times and to dedicate further pre-hospital resources to address the high burden of inter-facility transfers

Teaching Hands-Only CPR in Schools: A Program Evaluation in San José, Costa Rica

Background: Hands-only bystander CPR increases survival from out-of-hospital cardiac arrest. Video-based CPR instruction in schools has been proposed as a means to mass-educate laypersons in Hands-only CPR™ (HOCPR), in developed as well as developing countries. Objectives: The purpose of this study is to determine whether a brief video- and mannequin-based instructional program, developed by the American Heart Association (AHA), is an effective strategy for teaching Costa Rican middle- and high-school age children to learn the steps of HOCPR. Methods: This study took place in four educational centers that spanned the entire socioeconomic spectrum within the Grand Metropolitan Area of Costa Rica. Three hundred and eight students from the sixth to eleventh grades participated. The intervention included exposure to the AHA “CPR Anytime” video and practice with CPR mannequins. Before and after the intervention, students took a four-question, multiple-choice quiz that measured their knowledge of the correct steps and proper techniques of HOCPR; a separate question assessed their level of comfort “doing CPR on someone with a cardiac arrest.” Pre- and post-intervention “percent correct” scores were compared and tested for statistical significance using paired t-tests or the McNemar test as appropriate. Improvement in knowledge and comfort levels were also compared across the different educational centers and compared with similar programs implemented in the United States. Results: The students’ overall scores (mean percent correct) on the multiple choice questions more than doubled after training (40.9% ± 1.4% before training vs. 92.5% ± 0.9% after training, p < 0.00001). Improvements were observed in each school, regardless of geographic location or socioeconomic status. Knowledge of the appropriate steps of HOCPR doubled after training (42.2% before training vs. 92.5% after training, p < 0.000001). Post-intervention, a majority (73%) of children reported comfort with performing CPR on an individual who had suffered a cardiac arrest. Conclusion: This study demonstrates the effectiveness of the AHA “CPR Anytime” program in teaching HOCPR to school-age children within the Grand Metropolitan Area of Costa Rica. Additional studies are needed to measure longer-term knowledge retention and students’ ability to perform CPR in simulated cardiac arrest settings

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

Using the South African Triage Scale for prehospital triage: a qualitative study

Background Triage is a critical component of prehospital emergency care. Effective triage of patients allows them to receive appropriate care and to judiciously use personnel and hospital resources. In many low-resource settings prehospital triage serves an additional role of determining the level of destination facility. In South Africa, the Western Cape Government innovatively implemented the South African Triage Scale (SATS) in the public Emergency Medical Services (EMS) service in 2012. The prehospital provider perspectives and experiences of using SATS in the field have not been previously studied. Methods In this qualitative study, focus group discussions with cohorts of basic, intermediate and advanced life support prehospital providers were conducted and transcribed. A content analysis using an inductive approach was used to code transcripts and identify themes. Results 15 EMS providers participated in three focus group discussions. Data saturation was reached and four major themes emerged from the qualitative analysis: Implementation and use of SATS; Effectiveness of SATS; Limitations of the discriminator; and Special EMS considerations. Participants overall felt that SATS was easy to use and allowed improved communication with hospital providers during patient handover. Participants, however, described many clinical cases when their clinical gestalt triaged the patient to a different clinical acuity than generated by SATS. Additionally, they stated many clinical discriminators were too subjective to effectively apply or covered too broad a range of clinical severity (e.g., ingestions). Participants provided examples of how the prehospital environment presents additional challenges to using SATS such as changing patient clinical conditions, transport times and social needs of patients. Conclusions Overall, participants felt that SATS was an effective tool in prehospital emergency care. However, they described many clinical scenarios where SATS was in conflict with their own assessment, the clinical care needs of the patient or the available prehospital and hospital resources. Many of the identified challenges to using SATS in the prehospital environment could be improved with small changes to SATS and provider re-training

Validity and reliability of the South African Triage Scale in prehospital providers

Background The South African Triage Scale (SATS) is a validated in-hospital triage tool that has been innovatively adopted for use in the prehospital setting by Western Cape Government (WCG) Emergency Medical Services (EMS) in South Africa. The performance of SATS by EMS providers has not been formally assessed. The study sought to assess the validity and reliability of SATS when used by WCG EMS prehospital providers for single-patient triage. Methods This is a prospective, assessment-based validation study among WCG EMS providers from March to September 2017 in Cape Town, South Africa. Participants completed an assessment containing 50 clinical vignettes by calculating the three components — triage early warning score (TEWS), discriminators (pre-defined clinical conditions), and a final SATS triage color. Responses were scored against gold standard answers. Validity was assessed by calculating over- and under-triage rates compared to gold standard. Inter-rater reliability was assessed by calculating agreement among EMS providers’ responses. Results A total of 102 EMS providers completed the assessment. The final SATS triage color was accurately determined in 56.5%, under-triaged in 29.5%, and over-triaged in 13.1% of vignette responses. TEWS was calculated correctly in 42.6% of vignettes, under-calculated in 45.0% and over-calculated in 10.9%. Discriminators were correctly identified in only 58.8% of vignettes. There was substantial inter-rater and gold standard agreement for both the TEWS component and final SATS color, but there was lower inter-rater agreement for clinical discriminators. Conclusion This is the first assessment of SATS as used by EMS providers for prehospital triage. We found that SATS generally under-performed as a triage tool, mainly due to the clinical discriminators. We found good inter-rater reliability, but poor validity. The under-triage rate of 30% was higher than previous reports from the in-hospital setting. The over-triage rate of 13% was acceptable. Further clinically-based and qualitative studies are needed. Trial registration Not applicable

Assessing use of the South African triage scale in the Western Cape government emergency medical services system

Introduction: A critical concept underpinning emergency medicine is triage. Triage is the systematic process of sorting patients based on acuity and/or resource need, with the goal of getting the right person to the right place at the right time to receive the right level of care. Triage influences a patient's clinical trajectory, hence impacts both patient outcomes and health system resource utilization. Therefore, the consequences of triage are arguably even more critical in two scenarios: first, early on in the patient's care, such as the prehospital setting; and second, care in resource-constrained health systems, such as in Africa. Prehospital emergency care, delivered by Emergency Medical Services (EMS) providers, represents one of the earliest opportunities for emergency triage of the undifferentiated patient. We conducted a series of projects to, first, understand the current global scientific context of prehospital triage and, next, to better understand how the South Africa Triage Scale (SATS) is used by Western Cape EMS providers for prehospital triage. Findings may help enhance the application of SATS for prehospital triage in the Western Cape. Additionally, findings could provide evidence to encourage the adoption, or rejection, of SATS triage by other EMS systems in resource-constrained settings, especially in Africa. Methods: This project consisted of three distinct objectives which were investigated as separate, but interconnected, studies. The first objective was answered using a secondary research method (a scoping review) designed to discover and appraise existing prehospital triage tools across the world in an effort to better contextualise the specific role filled, and value added, by SATS. The second and third objectives were answered using a quantitative and qualitative approach, respectively, to assess the validity and reliability of SATS among EMS providers, and to understand EMS providers' experiences and perspectives using SATS. We converged the quantitative and qualitative data in a mixed methods analysis. Main results: In the scoping review, we screened 1521 unique articles and completed a full review of 55 articles. We reported that the majority of publications on prehospital triage tools were focused on stroke triage (35%) and trauma triage (35%). There were 15 (27%) publications, corresponding to 11 unique tools, relevant to prehospital triage of undifferentiated patients - overall, the tools had modest triage performance characteristics in high-income settings. However, we found no publications relevant to prehospital triage with SATS in the 2009 to 2019 study period, and no triage tools were studied in low- or middle-income countries. In the quantitative study, we conducted cognitive paper-based SATS triage assessments of 102 EMS providers of all qualifications within the Western Cape Government EMS system. We found a high rate (29.5%) of under-triage and an acceptable rate (13.1 %) of over-triage. Providers' use of the Triage Early Warning Score (TEWS) and the clinical discriminators were often incorrect in 41.4% and 41.2% of cases, respectively. In the qualitative assessment, we completed three focus group discussions with 15 diverse and representative providers from the Western Cape Government EMS system, and we achieved thematic saturation. Four major themes emerged from the discussions: Limited implementation and variable use of SATS; Prehospital effectiveness of SATS; Limitations of the discriminator; and, Special EMS considerations limiting SATS. In general, participants felt SATS was fairly easy to use and an asset in their patient care, explaining that it aided them clinically and with hospital communication. Participants, however, noted that the clinical discriminators were often challenging to apply in the prehospital setting, and the TEWS often did not reflect the patient's true or changing prehospital acuity. The qualitative findings both corroborated and helped explain some of the key quantitative results, with both suggesting that many clinical discriminators are problematic for prehospital use and manually calculating TEWS is an error-prone process for Western Cape EMS providers. Conclusion: SATS is being successfully and innovatively used in the prehospital triage of undifferentiated patients in the Western Cape of South Africa. Researching prehospital SATS in South Africa fills a global scientific gap given we found no reports of prehospital triage tools from low- or middle-income countries. Western Cape EMS participants reported that SATS was generally helpful and relatively easy to use, but reported challenges using TEWS and the clinical discriminators. SATS had good inter-rater reliability, but poor validity. The under-triage rate of 30% was high and attributable to misuse of TEWS and clinical discriminators. The over-triage rate of 13% was acceptable and confirmed by experiences recounted by the EMS participants. Modest adaptations of SATS by expert stakeholders could improve its prehospital performance and utility in the Western Cape Province. SATS for prehospital triage likely has good applicability and utility in other resource-constrained systems, but further adaptation and testing are warranted

Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana

African emergency medical services (EMS) systems are inadequate, thereby necessitating its selective use. This study aims to investigate differences in mode of arrival to the Emergency Centre (EC) at Komfo Anokye Teaching Hospital in Kumasi, Ghana by acuity, injury and referral status. Methods: A cross-sectional survey was conducted in the EC at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, in 2011. A survey was administered to all patients triaged to the EC. Patients were excluded if they were under 18 years of age, unable to communicate in English, Twi, or Fante, had altered mental status, or were deceased. Data were inputted into an excel spread sheet and uploaded to SPSS. Descriptive statistics were computed. Inferential statistics were performed testing for differences and associations between modes of arrival and acuity level, referral and injury status. Results: Of the 1004 patients enrolled, 411 (41%) had an injury-related complaint, and 458 (45.6%) were inter-facility transfers (“referrals”). 148 (14.8%) arrived by ambulance, and 778 (77.6%) non-ambulance (38% private cars, 38% taxis). 67 (6.7%) were triaged as Red, 276 (27.5%) as Orange, and 637 (63.4%) as Yellow (highest to lowest acuity). Ambulance arrival was positively associated with a higher triage score (OR: 1.53). Patients referred from other facilities were almost twice as likely (OR 1.92) to arrive at the KATH EC via ambulance than those not referred. Patients with injuries and higher acuities patients were more likely to be transported to KATH by ambulance (OR 1.86 and 1.87 respectively). All results are highly statistically significant. Conclusion: Although a minority of patients were transported by ambulance, they represented the most acute patients arriving at the KATH EC. Given the limited availability of EMS resources and ambulances in Ashanti, selective ambulance use appears warranted and should inform prehospital care planning