Research priorities for data collection and management within global acute and emergency care systems.

Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. These data gaps obscure the profound health effects of lack of emergency care access in low- and middle-income countries (LMICs). As part of the Academic Emergency Medicine consensus conference "Global Health and Emergency Care: A Research Agenda," a breakout group sought to develop a priority research agenda for data collection and management within global emergency care systems

Increased memory phenotypes of CD4+ and CD8+ T cells in children with sickle cell anaemia in Tanzania

Background: Infection is an important cause of morbidity in children with sickle cell anaemia (SCA). However, little is currently known regarding the spectrum of adaptive immune derangement in SCA, especially of populations in Sub-Saharan Africa. In this study, we investigated the phenotype and activation status of T and B lymphocytes among children with SCA in Tanzania.Methods: We compared 30 children with SCA aged 1–6 years in steady-state with 10 age-matched controls. We assessed white blood cell count, T and B lymphocyte phenotype and activation status using an automated haematology analyser and multiparameter Flow Cytometry.Results: In children with SCA, the absolute lymphocyte, monocyte and granulocyte counts were all increased. There was also an increase in proportion of central/transitional memory (42.4% vs. 33.3%, p = 0.0100), effector memory (7.8% vs. 5.4%, p = 0.0086) and terminally differentiated (2.3% vs. 1.3%, p = 0.0355) CD4+ T cells as well as effector memory CD8+ T cells (21.3% vs. 11.5%, p = 0.0060) in children with SCA. In contrast, there was no difference in naïve, classical memory, atypical memory and IgM memory B-cells between the two groups. The level of activation of both T and B cells were comparable between children with and without SCA. Furthermore, we observed a significant inverse correlation between frequency of the effector memory CD8+ T cells and haematocrit (Spearman rho = -0.3859, p = 0.0352). Conclusions: Children with SCA in Tanzania show an absolute increase in all leukocyte types, including lymphocytes, with skewing of both CD4+ and CD8+ T cells towards the memory phenotypes. These findings provide insights on the development of adaptive immunity which may have implications on vaccine responsiveness, allo-immunisation, auto-immune diseases and transplant immunology in children with SCA

Professional needs of young Emergency Medicine specialists in Africa: Results of a South Africa, Ethiopia, Tanzania, and Ghana survey

IntroductionEmergency Medicine (EM) residency programmes are new to Africa and exist in only a handful of countries. There has been no follow up on faculty development needs nor training of these graduates since they completed their programmes. The African Federation for Emergency Medicine (AFEM) aims to explore the needs of recent EM graduates with respect to the need for resources, mentorship, and teaching in order to develop a focused African faculty development intervention.MethodsAs part of the AFEM annual survey, all those who have graduated since 2012 from a Sub-Saharan African EM residency programme were approached. These included Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, Addis Ababa University (AAU) in Ethiopia, Komfo Anokye Teaching Hospital (KATH) in Ghana, the University of Cape Town (UCT) in South Africa, the University of Pretoria (UP) in South Africa, the University of Witswatersrand (Wits) in South Africa, and the University of KwaZulu-Natal (UKZN) in South Africa.ResultsThe 47 respondents rated themselves as most confident medical experts in knowledge, procedural skills, and communication. Overall graduates felt least equipped as scholars and managers, and requested more educational materials. They reported that the best way for AFEM to support them is through emergency care advocacy and support for their advocacy activities and that their most critical development need is for leadership development, including providing training materials.ConclusionRecent graduates report that the best ways for AFEM to help new EM graduates is to continue advocacy programmes and the development of leadership and mentorship programmes. However, there is also a demand from these graduates for educational materials, especially online

The Tanzanian Trauma patients' Prehospital Experience: A Qualitative Interview-based Study.

We sought to characterise the prehospital experience of Tanzanian trauma patients, and identify barriers and facilitators to implement community-based emergency medical systems (EMS). Our study was conducted in the emergency department of an urban national referral hospital in Tanzania. A convenience sample of 34 adult trauma patients, or surrogate family members, presenting or referred to an urban referral emergency department in Tanzania for treatment of injury, participated in the study. Participation in semistructured, iteratively developed interviews until saturation of responses was reached. A grounded theory-based approach to qualitative analysis was used to identify recurrent themes. We characterised numerous deficiencies within the existing clinic-to-hospital referral network, including missed/delayed diagnoses, limited management capabilities at pre-referral facilities and interfacility transfer delays. Potential barriers to EMS implementation include patient financial limitations and lack of insurance, limited public infrastructure and resources, and the credibility of potential first aid responders. Potential facilitators of EMS include communities' tendency to pool resources, individuals' trust of other community members to be first aid responders, and faith in community leaders to organise EMS response. Participants expressed a strong desire to learn first aid. The composite themes generated by the data suggest that there are myriad structural, financial, institutional and cultural barriers to the implementation of a formal prehospital system. However, our analysis also revealed potential facilitators to a first-responder system that takes advantage of close-knit local communities and the trust of recognised leaders in society. The results suggest favourable acceptability for community-based response by trained lay people. There is significant opportunity for care improvements with short trainings and low-cost supply planning. Further research looking at the effects of delay on outcomes in this population is needed

Differential Use of Diagnostic Ultrasound in U.S. Emergency Departments by Time of Day

Background: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours.Objective: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs.Methods: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy.Results: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED “off hours” (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during “off hours” were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during “off hours” (OR 0.56, 95% CI 0.35 - 0.91).Conclusion: In U.S. EDs, ultrasound use was lower during “off hours,” even among patient populations where its use would be strongly indicated. [West J Emerg Med. 2011;12(1):90-95.

Perceptions of health providers towards the use of standardised trauma form in managing trauma patients: a qualitative study from Tanzania

Background Trauma registries (TRs) are essential to informing the quality of trauma care within health systems. Lack of standardised trauma documentation is a major cause of inconsistent and poor availability of trauma data in most low- and middle-income countries (LMICs), hindering the development of TRs in these regions. We explored health providers’ perceptions on the use of a standardised trauma form to record trauma patient information in Tanzania. Methods An exploratory qualitative research using a semi-structured interview guide was carried out to purposefully selected key informants comprising of healthcare providers working in Emergency Units and surgical disciplines in five regional hospitals in Tanzania. Data were analysed using a thematic analysis approach to identify key themes surrounding potential implementation of the standardised trauma form. Results Thirty-three healthcare providers participated, the majority of whom had no experience in the use of standardised charting. Only five respondents had prior experience with trauma forms. Responses fell into three themes: perspectives on the concept of a standardised trauma form, potential benefits of a trauma form, and concerns regarding successful and sustainable implementation. Conclusion Findings of this study revealed wide healthcare provider acceptance of moving towards standardised clinical documentation for trauma patients. Successful implementation likely depends on the perceived benefits of using a trauma form as a tool to guide clinical management, standardise care and standardise data reporting; however, it will be important moving forward to factor concerns brought up in this study. Potential barriers to successful and sustainable implementation of the form, including the need for training and tailoring of form to match existing resources and knowledge of providers, must be considered

Trauma care and capture rate of variables of World Health Organisation data set for injury at regional hospitals in Tanzania: first steps to a national trauma registry

Background In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set. Methods This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. Results During the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. Conclusions In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry

Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research

The clinical presentation, utilization, and outcome of individuals with sickle cell anaemia presenting to urban emergency department of a tertiary hospital in Tanzania

Background Sickle cell anaemia (SCA) is prevalent in sub-Saharan Africa, with high risk of complications requiring emergency care. There is limited information about presentation of patients with SCA to hospitals for emergency care. We describe the clinical presentation, resource utilization, and outcomes of SCA patients presenting to the emergency department (ED) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Methods This was a prospective cohort study of consecutive patients with SCA presenting to ED between December 2014 and July 2015. Informed consent was obtained from all patients or patients’ proxies prior to being enrolled in the study. A standardized case report form was used to record study information, including demographics, relevant clinical characteristics and overall patients outcomes. Categorical variables were compared with chi-square test or Fisher’s exact test; continuous variables were compared with two-sample t-test or Mann-Whitney U-test. Results We enrolled 752 (2.7%) people with SCA from 28,322 patients who presented to the MNH-ED. The median age was 14 years (Interquartile range [IQR]: 6–23 years), and 395 (52.8%) were female. Pain 614 (81.6%), fever 289 (38.4%) were the most frequent presenting complaint. Patients with fever, hypoxia, altered mental status and bradycardia had statistically significant relative risk of mortality of 10.4, 153, 50 and 12.1 (p < 0.0001) respectively, compared to patients with normal vitals. Overall, 656 (87.2%) patients received Complete Blood Cell counts test, of these 342 (52.1%) had severe anaemia (haemoglobin < 7 g/dl), and a 30.3 (p = 0.02) relative risk of relative risk of mortality compare to patients with higher haemoglobin. Patients who had malaria, elevated renal function test and hypoglycemia, had relative risk of mortality of 22.9, 10.4 and 45.2 (p < 0.0001) respectively, compared to patient with normal values. Most 534 (71.0%) patients were hospitalized for in patients care, and the overall morality rate was 16 (2.1%). Conclusions We described the clinical presentation, management, and outcomes of patients with SCA presenting to the largest public ED in Tanzania, as well as information on resource utilization. This information can inform development of treatment guidelines, clinical staff education, and clinical research aimed at optimizing care for SCA patients

Emergency care in 59 low- and middle-income countries: a systematic review

Abstract Objective: To conduct a systematic review of emergency care in low- and middle-income countries (LMICs). Methods: We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards. Findings: We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. Conclusion: Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings