Global Research Review: Issue 13

Published on July 3, 2014
On behalf of the Global Emergency Medicine Literature Review Group


An analysis of patients presenting to the emergency departments in Kenya demonstrates a need for the development of a more sustainable emergency care system.

Wachira BW, Wallis LQ, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emergency Med J. 2012: 29:473-476.

Currently, emergency medicine is not an organized specialty in Kenya. Most of the ED’s are run by clinical officers and physicians who lack specific training in emergency medicine. There are very few published data on patients seen in the ED in Kenya or their clinical management. Most ED’s do not even keep records of the patients seen in the department. This is the first study to describe the profile and outcomes of patients presenting to ED’s in Kenyan hospitals: In this observational study, the authors sought to explore the range of demographics, chief complaints, interventions, and management of patients that presented to public emergency departments (ED’s) in Kenya. The study was conducted over a three month period from October 1 through December 31, 2010. A total of 15 public ED’s participated in the study, including two national referral hospitals, five secondary level hospitals, and eight primary level hospitals. All patients presenting alive to the ED who were seen by a doctor or clinical officer were included. Data collected on each patient included: age, sex, presenting complaint, investigations ordered, clinical management (including medications and procedures performed), diagnosis, and disposition. Any patient that had incomplete data or who had multiple ED visits was excluded from the study. Data on 1887 total patient presentations was obtained. Of the chief complaints, trauma-related (21%) and respiratory (20.8%) presentations were the most common. Only 545 (29%) of the patients received interventions in the ED, which included blood tests, imaging, and specimen tests (urinalysis, sputum cultures). Ultimately, 74% (n=1391) of the patients were discharged, 19% (n=354) were admitted to the wards, 7% (n=127) were referred to a specialist or other hospital, and <1% (n=8) went to emergency surgery.

Even though only 15 of the total 235 hospitals in Kenya were included in the study, the results appear to be representative of the typical patient profiles. One limitation of the study was that they were not able to determine bounceback rates or outcome data for the patients. The 3 month study period was also not long enough to evaluate for weekly or seasonal trends in the different hospitals. With Kenya’s growing population of over 38 million people, it is essential to develop a sustainable emergency care system for the country. This study highlights a number of important features of ED presentations and patient management in public hospitals across Kenya, which has significant implications for the development of this emergency care system. -TN, HD

South Africa

A needs assessment involving community leaders can facilitate the establishment of a first responder system that can appropriately assess and stabilize emergencies in the field.

Sun JH, Wallis LA. The emergency first aid responder system model: using com- munity members to assist life-threatening emergencies in violent, developing areas of need. Emerg Med J. 2012; 29:673-678.

This paper is a narrative analysis and post-intervention survey describing the establishment of a first responder system in a violent, resource-poor urban district in South Africa with poor access to Emergency Medical Services (EMS). The authors sought to identify a cost-effective strategy to improve EMS at the local level in this unique environment. They utilized a needs assessment followed by a pilot training course and first responder mobilization program. Local community needs were assessed by consultation with doctors and nurses in the local hospital and primary care clinics, local community members serving on the municipal Health Committee, and focus groups. The needs assessment identified four areas for training including emergency scene management, unconscious patient assessment and stabilization, violent injury care, and treatment of medical emergencies. There were 628 individuals who undertook a one-day training curriculum based on the needs assessment-identified topics. Knowledge-based pretest and posttest scores improved from 28.2% to 77.8%. Those trainees that scored at least 75% (n=423) were certified as Emergency First Aid Responders (EFARs) and were thereafter available in the community to offer first aid response when needed. A total of 274 EFARs completed a follow up exam at 4 and 6 months and demonstrated adequate knowledge retention. The authors reviewed a random selection of 29 patient care reports authored by EFARs and determined that appropriate care was delivered. The cost for the program was estimated to be US$700 for startup and US$6570 annually, based on 100 trainees per month.

The authors describe a well-planned and implemented program of training local first responders in a community that suffers from lack of rapid EMS dispatch. The utilization of local community members was essential for identifying those components of a training curriculum that were needed in this unique environment. The authors also sufficiently demonstrate that those trainees that were available for follow up had good knowledge retention, provided appropriate care, and were involved in treating conditions that had been taught in the course. However, the paper lacks clarity in adequately describing the methodology for either the needs assessment or the monitoring and follow-up of the trainees, which limits this program’s reproducibility.. A majority of the trainees were lost to follow up (56%), calling in to question the validity of the results. However, the project clearly had some impact on the community and came with a relatively low cost. The study demonstrates that involving local community members for buy-in, training, and monitoring is essential in the mobilization of first responders. -BH, TB

Trinidad and Tobago

In resource-limited settings, mixed opinions on the presence of relatives during CPR

Mahabir, D and Sammy, I. Attitudes of ED staff to the presence of family during cardiopulmonary resuscitation: a Trinidad and Tobago perspective. Emerg Med J 2012; 29:817-820.

This observational survey aimed at to determining the attitude and opinions of ED doctors and nurses in Trinidad and Tobago public hospitals towards the presence of relatives in the resuscitation room during cardiopulmonary resuscitation (CPR).

Over a 6-week period in 2009, a modified validated questionnaire was distributed to all ED doctors and nurses working in 8 public Trinidadian hospitals.

244 questionnaires were distributed to the entire population of 254 ED staff members in all 8 hospitals, with 214 responses (106 doctors and 108 nurses), a response rate of 85.65%. The authors found mixed attitudes and opinions regarding the presence of family members in the ED during CPR in this developing Caribbean country. 51.9% of ED doctors and nurses in Trinidad and Tobago disagreed with the presence of relatives in the resuscitation room.

The presence of family members in the resuscitation room during CPR is increasingly accepted in developed countries. But in resource limited settings, the authors showed that attitudes were mixed about the presence of relatives during CPR. The high methodological quality of this study is highlighted by the high response rate (85.65%), predetermined power calculation and the use of validated questionnaire. The authors offer physical infrastructural changes and educational training as solutions to acceptance of relatives witness CPR in Trinidad and Tobago.

The authors acknowledged some limitations imposed by exclusion of part time staff and under-representation of senior medical and nursing staff. But the lack of numerical data respectively of the proportion of teaching and district hospitals and ED staff with previous CPR experience introduced further limitations. The authors made no effort to minimise or analyze the effects of missing data such as unrecorded gender (10.2%), unrecorded ethnicity (6.5%), and unrecorded religion (18%). -OJ, MF


TN: Theresa Nguyen, MD
HD: Herbie Duber, MD, MPH
BH: Braden Hexom, MD
TB: Torben K. Becker, MD
OJ: Okechukwu Ogbonna Jibuike, MD
MF: Mark Foran, MD, MPH

This article originally appeared in Issue 13 of Emergency Physicians International.

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