African Journal of Emergency Medicine最新文献

Background

Palliative Care offers patient-centered, symptom-focused relief for patients with incurable disease, and early integration of palliative care ensures quality of life and death while reducing medical impoverishment. The Emergency Department is an ideal yet understudied, under-utilized location to initiate palliative care.

Objective

To evaluate the palliative care needs of patients with incurable disease and perceived barriers amongst healthcare providers in the Emergency Department of Kiruddu National Referral Hospital, Kampala, Uganda.

Methods

A mixed methods survey of Emergency Department healthcare workers and patients was conducted. A crosse sectional survey of ninety-nine patients was conducted using the integrated Palliative Care Outcome Scale (IPOS). Eleven interviews were conducted with healthcare workers at Kiruddu Hospital, identified by purposive sampling. Descriptive and inferential statistics were used to analyze quantitative data.. Grounded theory approach was used to construct the in depth interview questions, code and analyze qualitative results and collapse these results into final themes.

Results

The most common diagnoses were HIV/HIV-TB (32 %), heart disease (18 %), and sickle cell disease (14 %). The prevalence of unmet palliative care needs was substantial: more that 70 % of patients reported untreated symptoms e.g., pain, fatigue, difficulty breathing. Seventy-seven percent of the population reported severe or overwhelming pain. The main barriers to provision of palliative care in the Emergency Department as identified by healthcare workers were: (1) lack of adequate training in palliative care; (2) Challenges due to patient volume and understaffing; (3) the misconception that palliative care is associated with pain management alone; (4) Financial constraints as the greatest challenge faced by patients with incurable disease.

Conclusions

We report a high prevalence of unmet palliative care needs among patients in this urban Ugandan Emergency Department, and important barriers reported by emergency healthcare providers. Identification of these barriers offers opportunities to overcome them including harnessing novel mHealth interventions such as clinical support apps or telehealth palliative care consultants. Integration of palliative care in this setting would improve the care of vulnerable patients, provide healthcare workers with an additional care modality while likely adding value to the health system.

Background

Historically, educational initiatives in global health have involved expert lectures by visitors. However, incomplete understanding of the target population and resources can limit the efficacy of lectures by international faculty. Little data exists on the magnitude of this problem. The goal of this study was to create and validate a needs assessment tool to guide lecture development as part of a larger study to implement virtual lectures for a residency program in Tanzania by members of an American faculty.

Methods

Two study authors familiar with the Tanzanian hospital and residency program derived surveys for local residents and faculty. An expert panel consisting of two faculty members and one resident from each institution evaluated the questions. Each item was rated from 1 to 4 for clarity and relevance respectively. A content validity index (CVI) was calculated for each item using the proportion of experts who rated it as valid. Items with a CVI < 0.8 were revised and resubmitted. A CVI was then calculated for each instrument.

Results

On the initial resident survey, 20 of 26 items were clear and 25 of 26 items were relevant with a CVI > 0.8. One item was deemed irrelevant and deleted. For the faculty survey, 10 of 12 items were clear and all items were relevant with CVI > 0.8. Five questions from the resident survey and two from the faculty survey deemed relevant but unclear were rewritten and resubmitted to experts. They all achieved CVI>0.8. Each survey obtained a CVI of 1.

Conclusions

Using this approach, we validated a needs assessment tool to guide the creation of didactics for audiences that practice in a different setting from the lecturer.  This validated tool is an important step in the creation of a process to develop appropriate content and could be replicated by other groups planning similar initiatives.

Introduction

Reliable systematic reviews are essential to inform clinical practice guidelines, policies and further research priorities in Africa. For systematic review findings to be trustworthy, they need to be conducted with methodological rigour and reported transparently. We assessed the methodological quality of systematic reviews published in African emergency medicine journals, comparing them to those published in international emergency medicine journals. Additionally, we describe the types of review literature published in the African journals.

Methods

We performed a cross-sectional methodological study of systematic reviews published in selected African and international emergency medicine journals from 2012 to 2021. Studies were eligible if they were i) a systematic review on an emergency medicine topic, ii) published in one of the top five emergency medicine journals in the African region or internationally and iii) published between January 2012 and December 2021 in English or French. We searched PubMed, Web of Science and Scopus databases and hand-searched selected journals. Two authors screened titles, abstracts and full texts independently and in duplicate. Data extraction was performed by one reviewer, using a standardised form, after completing a calibration exercise. We described the characteristics of systematic reviews and assessed methodological quality using AMSTAR II.

Results

We identified 34 (37%) African and 511 (54%) international systematic reviews from 92 and 948 review articles respectively across 10 journals. We included all 34 African and a random sample of 100 international systematic reviews. Methodological quality was low or critically low for all the African systematic reviews (n=34, 100%) and all but three international systematic reviews (n=97, 97%). The median number of critical domain weaknesses was 4 (IQR 4;5) and 2 (IQR 2;4) for African and international systematic reviews respectively. The most common weaknesses across both African and international systematic reviews were i) not establishing a priori review protocols, ii) unclear selection of study designs iii) not providing a list of excluded studies and iv) unclear reporting on funding sources for included studies.

Conclusion

Emergency medicine systematic reviews published in African and international journals are lacking in methodological quality. Reporting an a priori protocol, developing a comprehensive search strategy, appropriate evidence synthesis and adequate assessment of risk of bias, heterogeneity and evidence certainty may improve the quality of systematic reviews.

Introduction

Non-invasive ventilation (NIV) is an alternative ventilatory method to endotracheal intubation and invasive ventilation in patients presenting in acute respiratory failure. Appropriate and timely application of NIV has shown benefits over invasive ventilation. In recent years, there has been an increase in the use of NIV for varying pathologies in response to limited resources.

Emergency department doctors’ knowledge of NIV, as well as their attitude towards its use can have significant effects on the success of NIV. The aim of this study was to assess emergency doctors’ use of NIV in the South African setting.

Methods

This was a multi-centre prospective cross-sectional study that was conducted across three academic emergency departments in Johannesburg, South Africa. Doctors of various grades were included in the study and their responses were analysed according to their level of experience and their job description.

Results

The mean knowledge score of the participants was shown to increase with an increase in job designation (p < 0.001). The doctors’ attitude towards NIV was more positive in those with higher knowledge scores (p < 0.001). Participants with previous critical care experience versus those without was associated with a higher average knowledge score (77% vs. 69 %, p = 0.009) as was formal NIV training versus those without (77% vs. 69 %, p = 0.01). The COVID-19 pandemic increased confidence in the use of NIV in 61 % of participants. The majority (69 %) of participants did not use a checklist when administering NIV. Only 53 % used a guideline when initiating a patient on NIV and just 26 % used a locally produced protocol.

Conclusion

Increased clinical experience, critical care exposure and formal NIV training corresponded with higher knowledge scores. Formal NIV training programs, the implementation of a checklist and the development of locally produced protocols are recommended to improve knowledge, attitudes and NIV practice that is in-keeping with international standards.

Background

The effectiveness of ketamine as adjunctive or monotherapy for post-intubation sedation in adults with trauma on mechanical ventilation is unclear.

Methods

A rapid review of systematic reviews of randomized controlled trials, then randomized controlled trials or observational studies was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on June 1, 2022. We used a prespecified protocol following Cochrane rapid review methods.

Results

We identified eight systematic reviews of randomized controlled trials and observational studies. Among the included reviews, only the most relevant, up to date, highest quality-assessed reviews and reviews that reported on critical outcomes were considered. Adjunctive ketamine showed a morphine sparing effect (MD −13.19 µmg kg^–1 h^–1, 95 % CI −22.10 to −4.28, moderate certainty of evidence, 6 RCTs), but no to little effect on midazolam sparing effect (MD 0.75 µmg kg^–1 h^–1, 95 % CI −1.11 to 2.61, low certainty of evidence, 6 RCTs) or duration of mechanical ventilation in days (MD −0.17 days, 95 % CI −3.03 to 2.69, moderate certainty of evidence, 3 RCTs).

Adjunctive ketamine therapy may reduce mortality (OR 0.88, 95 % CI 0.54 to 1.43, P = 0.60, very low certainty of evidence, 5 RCTs, n = 3076 patients) resulting in 30 fewer deaths per 1000, ranging from 132 fewer to 87 more, but the evidence is very uncertain. Ketamine results in little to no difference in length of ICU stay (MD 0.04 days, 95 % CI −0.12 to 0.20, high certainty of evidence, 5 RCTs n = 390 patients) or length of hospital stay (MD −0.53 days, 95 % CI −1.36 to 0.30, high certainty of evidence, 5 RCTs, n = 277 patients).

Monotherapy may have a positive effect on respiratory and haemodynamic outcomes, however the evidence is very uncertain.

Conclusion

Adjunctive ketamine for post-intubation analgosedation results in a moderate meaningful net benefit but there is uncertainty for benefit and harms as monotherapy.

Background

Shortages in the right cadres of human resources to manage health emergencies remain an acute problem especially in low- and middle-income countries. Efforts to address this challenge are dependent on the knowledge and competency of emergency nurses. We sought to determine the knowledge level of nurses in emergency management in the Ashanti Region of Ghana.

Methods

We used a cross-sectional, quantitative approach to evaluate knowledge about emergency care among 408 nurses working in wards and emergency units in 11 randomly selected district hospitals (6 public and 5 faith-based). Participants were purposively selected and examined on knowledge level using a structured questionnaire. The inclusion criteria were different cadres of nurses who had spent at least 6 months in the selected hospitals.

Results

Four hundred and eight nurses participated. Most were general nurses (73.1 %) or mid-wives (14.4 %), with few specialised in emergency nursing (3.9 %) or critical care nursing (1.6 %). Mean percentage correct on an objective 20 question test on emergency care was 59.8 %. Few (35.6 %) nurses felt that they had adequate knowledge to manage emergencies. Around half (52.5 %) had received training in managing critically ill and injured patients through continuing professional development and 46.6 % felt prepared to work at emergency units. But few (34.7 %) reported having adequate logistics to manage emergencies and fewer (32.2 %) had time off to access training opportunities. Predictors of reporting adequate knowledge to manage emergencies included: having received training in managing critically ill and injured patients (p<.002), feeling prepared to work at emergency units (p<.001), and having adequate logistics to manage emergencies (p<.001).

Conclusion

Most nurses did not feel that they had adequate knowledge to manage emergencies. This study has identified increased availability of continuing professional development on emergency care for nurses as a priority in Ghana.

Introduction

Burundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery.

Methods

In June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant.

Results

Forty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01).

Conclusion

Burundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.

Introduction

Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital.

Methods

A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital.

Results

A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55–5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60–2.37; p<0.01).

Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36–15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10–3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51–2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54–2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21–1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11–6.41; p<0.01)).

Conclusion

This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS.

Introduction

Triage is the most important step in patients’ journey through an Emergency Centre (EC) and directly impacts time to critical actions. Triage tools, like the South African Triage Scale, are however not designed to predict patient outcomes. The shock index (SI), modified shock index (MSI) and age shock index (ASI) are clinical markers derived from vital signs and correlate with tissue perfusion in critically ill patients. This study aimed to assess the value of SI, MSI and ASI to predict mortality and the need for hospitalisation in all adult patients presenting to a district level emergency centre in South Africa.

Methods

This diagnostic study was performed as a retrospective observational study, using data from an existing electronic registry at a district level hospital emergency centre over a period of 24 months. All adult patients who presented to Mitchells Plain Hospital were eligible for inclusion. Sensitivity, specificity and likelihood ratios were calculated for each variable as a predictor of mortality and hospitalisation with pre-determined thresholds.

Results

During the study period of 24 months, a total of 61 329 patients ≥ 18 years old presented to the EC with 60 599 included in the final sample. A red SATS triage category (+LR = 7.2) and SI ≥1.3 (+LR = 4.9) were the only two predictors with any significant clinical value. The same two markers performed well for both patients with and without trauma and specifically for patients who died while under the care of the emergency centre.

Discussion

The study demonstrated that patients with a SI≥1.3 at triage have a significantly higher likelihood to die or require hospitalisation, whether the presenting complaint is trauma related or not, especially to predict mortality while under the care of the EC. Incorporating this marker as a triage alert could expedite the identification of patients requiring time critical interventions and improve patient throughput in the emergency centre.