Emergency department quality and safety indicators in resource-limited settings: an environmental survey

Background: As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings. Methods: We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian’s structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89. Results: A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care. Conclusions: The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization. Electronic supplementary material The online version of this article (doi:10.1186/s12245-015-0088-x) contains supplementary material, which is available to authorized users

Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone

Background: Postpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone. Methods: Data were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis. Results: Of the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely. Conclusion: The ESM-UBT device appears safe for use in women with uncontrolled PPH. Trial registration Trial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit

The need to create a global fund for STEM education

<p>In today’s global economy, a workforce trained in science, technology,engineering and maths (STEM) is recognised as a primary driver of growth. Around the world, STEM education initiatives vary in scope, size, type, target populations and funding sources. What’s missing is a unified global mechanism for STEM education. </p> <p>A global fund to widen quality STEM education would be a vital economic driver. Its first task would be to assess the success of existing initiatives in the developing world. Access to quality science education should be among the forthcoming development goals</p

Additional file 1: of Emergency department quality and safety indicators in resource-limited settings: an environmental survey

Appendix 1. Included Articles (non WHO/IATSIC). Appendix 2. Included Articles (WHO/IATSIC). (DOCX 96.9 kb

Feasibility of a ketamine anesthesia package in support of obstetric and gynecologic procedures in Kenya when no anesthetist is available

The objective was to assess the feasibility and safety of the ‗Every Second Matters for Emergency and Essential Surgery – Ketamine‘ (ESM-Ketamine) package in support of obstetric and gynecologic emergency and essential surgery when no anesthetist is available. A consecutive case series was conducted in twelve hospitals across five severely resource-limited counties in Kenya. 530 women underwent obstetric or gynecological operative procedures supported by non-anesthetist clinicians using the ESM-Ketamine package between November 1, 2013 and September 30, 2017. Main outcomes included reasons for ESM-Ketamine activations and ketamine-related adverse events. There were two (0.4%) prolonged (&gt;30 seconds) oxygen desaturations below 92%. Brief oxygen desaturations (&lt;30 seconds) below 92% occurred in 15 (2.8%) cases and 113 (21.3%) were administered diazepam to treat hallucinations or agitation. There were no ketamine-related deaths or injuries. The ESMKetamine package appears feasible and safe for use in support of obstetric and gynecologic surgeries when no anesthetist is available. Keywords: Obstetrics, Gynecology, Anesthesia, Ketamine, low-resource settings L‘objectif était d‘évaluer la faisabilité et la sécurité du paquet «Chaque seconde compte pour la chirurgie urgente et essentielle – L‘ensemble Kétamine» (CSC-Kétamine) à l‘appui de l‘urgence obstétricale et gynécologique et de la chirurgie essentielle en l‘absence de l‘anesthésiste. Une série de cas consécutifs a été menée dans douze hôpitaux du Kenya, dans cinq comtés aux ressources limitées. Entre le 1er novembre 2013 et le 30 septembre 2017, 530 femmes ont subi une intervention chirurgicale gynécologique ou obstétricale soutenue par des cliniciens non anesthésistes, à l'aide du progiciel CSC-Kétamine. Les principaux résultats comprenaient les raisons des activations de la Kétamine et des événements indésirables liés à la kétamine. Deux (0,4%) désaturations prolongées en oxygène (&gt; 30 secondes) étaient inférieures à 92%. Des désaturations brèves en oxygène (&lt;30 secondes) inférieures à 92% sont survenues dans 15 cas (2,8%) et 113 (21,3%) ont reçu du diazépam pour traiter des hallucinations ou une agitation. Il n'y a eu aucun décès ou blessure lié à la kétamine. Le progiciel CSC-Kétamine semble utilisable et sans danger pour les chirurgies obstétricales et gynécologiques lorsqu'aucun anesthésiste n'est disponible.  Mots-clés: Obstétrique, gynécologie, anesthésie, kétamine, paramètres à faibles ressource

Ketamine for sedation in acutely painful procedures in Kenya: findings after implementation of the Every Second Matters-Ketamine package

Background: Adequate pain management for painful procedures improves the quality and safety of patient care and has become accepted as a basic human right. In low-resource settings, pain relief for painful procedures is scarce because of cultural, attitudinal, legal, and system-related reasons, as well as a scarcity of anaesthetists. A practice of “hold still”, where patients are forcibly held down during painful procedures, remains common in Kenya and in other low-resource settings. In December, 2013, we launched the Every Second Matters-Ketamine (ESM-Ketamine) package in Kenya, for use during emergency surgery when no anaesthetist is available. Here, we aim to describe how non-anaesthetists who were trained in an ESM-Ketamine programme broadened use of their skills to provide procedural sedation for patients in need of painful procedures when an anaesthetist would not have been previously called. Methods: Medical officers, nurses, and clinical officers in Kenya undertook a 5-day ESM-Ketamine competency-based training programme for non-anaesthetists. We provided every facility in the ESM-Ketamine initiative with wall charts, checklists, and kits. Trained providers recorded patients' demographic data, pre-operative diagnoses, the procedure or procedures undertaken, medications administered, and ketamine-related adverse events. Partners Healthcare and Maseno University gave ethical approval for the programme. Findings: Between Dec 1, 2013, and July 30, 2018, 62 ESM-Ketamine providers across 11 facilities administered ketamine to 512 patients undergoing painful procedures in non-training settings where an anaesthetist would previously not have been called. 273 patients (53·3%) were male and median age was 23 years (IQR 11–36 years). The five most common indications were: incision and drainage, debridement, or both (159 [31·1%]); fracture reduction (56 [10·9%]); circumcision (41 [8·0%]); wound repair (29 [5·7%]); and foreign body removal (26 [5·1%]). Median ketamine dose was 2·0 mg/kg (IQR 2·0 –3·0). Hallucinations or agitation treated with diazepam were reported in 45 patients [8·8%]; brief oxygen desaturation occurred in 22 (4·3%) patients. Prolonged (>30s) desaturations below 92% occurred in two patients (0·4%). The lowest desaturation was 85%. All patients recovered uneventfully. There were no deaths or injuries associated with ketamine use in the programme. Interpretation: The ESM-Ketamine package appears safe for use by trained providers in support of procedural sedation when previously an anaesthetist would not have been called. Scale-up of the ESM-Ketamine package may support the human rights imperative that every person deserves pain relief when undergoing a painful procedure. Funding: None

Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response