Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya

Background: In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world. Methods: We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status. Results: We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5­6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1­10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5­14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%. Conclusion: Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities

Building focused cardiac ultrasound capacity in a lower middle-income country: a single centre study to assess training impact

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agree-ment between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training pro-gramme locally. Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were as-sessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa > 0.6 indicative of good inter-rater agreement. Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives

Emergency medical services (EMS) training in Kenya: Findings and recommendations from an educational assessment

Background.Over the past twenty years, Kenya has been developing many important components of a prehospital emergency medical services (EMS) system. This is due to the ever-increasing demand for emergency medical care across the country. To better inform the next phase of this development, we undertook an assessment of the current state of EMS training in Kenya.Methods.A group of international and Kenyan experts with relevant EMS and educational expertise conducted an observational qualitative assessment of Kenyan EMS training institutions in 2016. Three assessment techniques were utilised: semi-structured interviews, document review, and structured observations. Recommendations were reached through a consensus process amongst the assessment team.Results.Key findings include: (i) No national or state-level policy exists that establishes levels of EMS providers or expected fund of knowledge and skills; (ii) Training institutions have independently created their own individual training standards; (iii) Training materials are not adapted for the local context; (iv) The foundation of basic anatomy and physiology education is weak; (v) Training does not focus on symptom- or syndrome-based complaints; (vi) Students had difficulty applying foundational classroom knowledge in simulations and clinical encounters; (vii) There is limited emphasis on complex critical thinking.Discussion.Standardisation of training is needed in Kenya, including clearly defined levels of providers and expected learning outcomes. A nationally standardised EMS provider scope of practice may also help focus EMS education. Instructors must reinforce basic anatomy and physiology amongst all trainees to establish a robust foundation, then layer on field experience before trainees receive advanced training. Training graduates should be EMS providers who approach patient care with high-order symptom- or syndrome-based critical thinking. While these recommendations are specific to the Kenyan EMS environment, they may have wider applicability to other developing EMS systems in resource-limited settings

Characterization of in-hospital cardiac arrest in adult patients at a tertiary hospital in Kenya

Background: In-hospital cardiac arrest (IHCA) is defined as a cardiac arrest that occurs in a hospital and for which resuscitation is attempted. Despite the increased morbidity and mortality, IHCA incidence and outcomes remain largely unknown especially in sub-Saharan Africa. This study describes the baseline characteristics, prearrest physiological parameters and the rate of survival to hospital discharge of adult patients with an IHCA at a tertiary hospital in Kenya. Methods: This was a retrospective chart review. Data on patient characteristics, pre-arrest physiological parameters and discharge condition were collected on all patients 18 years of age or older with an IHCA at the Aga Khan University Hospital, Nairobi, from January 2013 to December 2013. Results: The main study population comprised 108 patients. The mean age was 59.3 ± 18.4 years and 63 (58.3%) patients were men. The initial rhythm post cardiac arrest was pulseless electrical activity (41.7%) or asystole (35.2%) in the majority of cases. Hypertension (43.5%), septicaemia (40.7%), renal insufficiency (30.6%), diabetes mellitus (25.9%) and pneumonia (15.7%) were the leading pre-existing conditions in the patients. A Modified Early Warning Score (MEWS) of 5 or more was reached in 56 (67.5%, n= 83) patients before the cardiac arrest. The rate of survival to hospital discharge was 11.1%. All the patients who survived to hospital discharge had a good neurological outcome. Conclusions: Early identification of warning signs that precede many in-hospital arrests may enable institution of treatment to prevent patient deterioration. Local hospitals should be encouraged to provide patients with resuscitation services and equipment in line with evidence-based programmes