The Best of AfJEM

Published on May 2, 2014
A review of recent research from the African Journal of Emergency Medicine

In terms of acute care, Africa remains the dark horse of international emergency medicine. Its reputation as the continent with some of the world’s highest injury and acute illness mortality figures is starkly contrasted by its almost non-existent acute care infrastructure, low staffing and lack of equipment. Not surprisingly, very few publications come out of this continent and those that do mainly report on its failures rather than successes. Of course this is not all bad, as understanding the problems allows us to lay the foundation for improvements. This was the theme of the most recent issue of the African Journal on Emergency Medicine (volume 4, issue 1). The following are highlights from three of the most accessed original research papers in this issue.

1 Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana by Mould-Millman, et al. is an observational study analysing the mode of, and illness/injury severity of patients arriving at a Ghanaian emergency centre (EC). The study included all consenting attendees to the EC for a month in July/August 2011 and excluded those that were unable to be consented, did not speak English, Twi or Fante, had an altered level of consciousness or required resuscitation on arrival. The main gist of the study is described in Table 1. Essentially the majority of patients, regardless of illness or injury severity, tend to make their own way to hospital making use of public transport or a private vehicle (76.6%). Ambulance transported patients did tend to be sicker - odds ratio of 1.5 (95% confidence intervals 1.0-2.3) - although this is hardly reassuring given that only 15% of patients were ambulance transported, with the majority of high acuity patient making their way through other means. The authors quote five barriers to ambulance use which include: lack of availability, poor accessibility, non-affordability, inadequacy and poor acceptance of ambulances. They correctly point out that further research is needed to specifically look at which of these barriers contributed to their findings. One wonders how many never made it to the EC. On the upside, the Ghanaian government did introduce paramedics to the national ambulance service a few years ago to complement the existing basic life support crews. As with any new service, especially an inexperienced one that delivers a national service in a resource challenging environment, it would take time to develop to its full potential. When this study is repeated in another decade, it’ll most likely tell a whole different story.

2 Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities by House, et al. is an observational cohort study describing the demographics of attendance at a single Kenyan EC during 2011. The authors utilised attendance and admission records as a data source and only patients with insufficient record keeping were excluded. Data were anonymised to protect patient identity and consent was not individually sought. Almost half of attendees were between the ages of 15 and 30 (47%) with a mean age of 36 years. Interestingly daily attendance variation appeared pretty similar to what would be expected in Western ECs suggesting a universal diurnal cycle. The majority of patients attended during the day with a steep peak around midday, a plateau till around 1800, which then tapered off slowly towards the morning hours. The top ten findings for chief complaints, EC and admission diagnoses could however not be more different. In addition to more commonly seen diagnoses in Western ECs, early pregnancy complaints, organophosphate poisoning and psychosis’ ranking suggests regional inadequacies in public health priorities. Furthermore HIV does not feature on any of the top ten lists, a fact which is in keeping with reports that Sub-Saharan Africa has at least achieved control of the epidemic. It is noteworthy that patients pay around a day’s wage to be attended to at this public sector EC. This is beyond a doubt a barrier to acute care access. The authors rightfully point out that there are many challenges faced within a resource limited acute care setting and their paper goes a long way to expose some of these.

3 Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania by Aloyce, et al. evaluates the triage skills of 66 EC nurses in four different ECs in Dar es Salaam, a city of 1.36 million. There were three parts to the study; the first evaluated nurses’ knowledge of triage, the second concerned the ECs triage service and the third the equipment available to triage. The majority of nurses (78%) had no acute care training beyond their basic training and most were only recent graduates (47% graduated in the last year). Triage was not addressed or minimally addressed in in-service training which only half of nurses had attended. Not surprisingly, only 48% of nurses were able to triage scenario-based cases to the correct priority. Only one EC had a dedicated triage service. The other units essentially divided patients into ambulatory and non-ambulatory streams (the latter which was afforded a higher priority). Vital signs were performed as far as mechanical devices allowed (a brief history, respiratory rate and pain assessment were omitted by most). The ED with a dedicated triage service was also the one with the most appropriate equipment available. Whilst I appreciate that most Western ECs are currently moving away from using triage (due to better staffing levels, lower acuity and the introduction of rapid assessment services) a comparison with an under-resourced African EC couldn’t be more different. Long waiting times due a predominantly junior work force, understaffing and lack of appropriate training, in addition to high volumes, high acuity pathology as well as the lack of an efficient prehospital service should be enough to motivate the role of triage as a basic acute care skill in any resource poor setting.

Commentary

All these issues undeniably impact negatively on acute care. They cost not just patient lives, but also the simple ability to return to work after an injury or acute illness. It is therefore imperative that African acute care workers consider less expensive, lower resource consuming, innovative short-cut solutions. Instead of providing a fleet of ambulances that will require roads, fuel, and staff why not train taxi drivers or communities to provide a basic proxy. Simple triage systems such as the South African Triage Scale requires very little training to be effectively used by even the most junior nursing staff members for prioritising acute care. And acute care workers can continue to come up with new equipment and procedure hacks such as described in the practical pearl feature (Ujuzi). Of course in most other settings such solutions would be viewed as temporary, a sticking plaster to cover a leaky pipe. Sadly, in Africa much depends on the effectiveness of such sticking plaster solutions and all too often these are relied upon as permanent solutions. Real solutions will require sheer determination aimed at several levels of government (local and national), specifically targeting those in leadership positions with a real passion for improving acute care and changing the way they view acute healthcare provision. It will also require the private sector to contribute (as they did with the HIV epidemic), but this will need proof of benefit to get private cash in the mix. This proof is most likely present in all shapes and forms in Africa, but since much of this activity remains unreported, a mighty private sector solution remains dormant. It is the AfJEM’s niche to report on evidence based solutions in resource constrained settings as it will be this information that will drive the local acute care knowledge economy, putting theory into practice on a larger scale and ensuring safe, accessible acute care for all Africans. If you wish to contribute to the AfJEM please visit our official website for more information (www.afjem.com).

References

  1. Mould-Millman CN, Rominski S, Oteng R. Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana. African Journal of Emergency Medicine. 2012;4(1):8-13

  2. Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania. African Journal of Emergency Medicine. 2012;4(1):14-18

  3. House DR, Nyabera SL, Yusi K, Rusyniak DE. Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities. African Journal of Emergency Medicine. 2012;4(1):19-24

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