Seeking and reaching emergency care: A cross sectional household survey across two Liberian counties.

The overwhelming burden of morbidity and mortality from injury and medical conditions requiring acute care are borne by low- and middle-income countries lacking accessible, quality care systems. Current evidence suggests the lack of prehospital care systems likely contributes to this disproportionate burden. As an initial step in a longitudinal, collaborative effort to strengthen the chain of survival for emergency conditions in Liberia, baseline attitudes and behaviors in accessing and utilizing emergency care were characterized. A multistage, proportional, cluster sampling frame was employed to conduct a cross-sectional, community-based survey of 800 households across rural Lofa County and the greater capital (Monrovia) metropolitan area. The primary outcome was facility-based utilization of emergency care within the 12 months prior to survey administration. 43.9% of individuals surveyed reported a visit to an emergency unit in the last year. Multivariable logistic regression revealed increased adjusted odds of facility-based emergency care utilization in households that were low-income, non-English-speaking, lacking electricity, or had a non-durable roof. Among these individuals, 23.6% had sought care from a community health worker, family/friend, clinic, pharmacy, or traditional healer prior. The majority of persons seeking care do so without ambulance services. 34.8% of all households have called a community member for a medical emergency, but 88.9% of survey respondents report no first aid training and cite barriers to rendering aid. This represents the first household survey to assess the perceptions and utilization of emergency care in Liberia. Formal pre-hospital care provision is limited and substantial barriers to emergency care access exist. First aid training and acceptance is lacking, despite frequent reliance on community-based aid during emergencies.

Emergency care interventions for paediatric severe acute respiratory infections in low- and middle-income countries: A systematic review and narrative synthesis.

Background: Severe acute respiratory infections (SARIs) are the leading cause of paediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care are critical to improving patient outcomes. Through this systematic review, we aimed to evaluate the impact of emergency care interventions on improving clinical outcomes of paediatric patients with SARIs in LMICs. Methods: We searched PubMed, Global Health, and Global Index Medicus for peer-reviewed clinical trials or studies with comparator groups published before November 2020. We included all studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs. Due to observed heterogeneity of interventions and outcomes, we performed narrative synthesis. We assessed bias using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions tools. Results: We screened 20 583, 99 of which met the inclusion criteria. Conditions studied included pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). Studies evaluated medications (80.8%), respiratory support (14.1%), and supportive care (5%). We found the strongest evidence of benefit for decreasing risk of death for respiratory support interventions. Results were inconclusive on the utility of continuous positive airway pressure (CPAP). We found mixed results for interventions for bronchiolitis, but a possible benefit for hypertonic nebulised saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes. Conclusions: Despite the high global burden of SARI in paediatric populations, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for benefit. Further research on the use of CPAP in diverse settings is needed, as is a stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions. Registration: PROSPERO (CRD42020216117).

Clinical emergency care quality indicators in Africa: a scoping review and data summary.

OBJECTIVES: Emergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This study sought to increase knowledge of quality through identifying all publications from Africa containing data relevant to the AFEM-CC process clinical and outcome quality indicators. DESIGN: We conducted searches for general quality of emergency care in Africa and for each of 28 AFEM-CC process clinical and five outcome clinical quality indicators individually in the medical and grey literature. DATA SOURCES: PubMed (1964-2 January 2022), Embase (1947-2 January 2022) and CINAHL (1982-3 January 2022) and various forms of grey literature were queried. ELIGIBILITY CRITERIA: Studies published in English, addressing the African emergency care population as a whole or large subsegment of this population (eg, trauma, paediatrics), and matching AFEM-CC process quality indicator parameters exactly were included. Studies with similar, but not exact match, data were collected separately as 'AFEM-CC quality indicators near match'. DATA EXTRACTION AND SYNTHESIS: Document screening was done in duplicate by two authors, using Covidence, and conflicts were adjudicated by a third. Simple descriptive statistics were calculated. RESULTS: One thousand three hundred and fourteen documents were reviewed, 314 in full text. 41 studies met a priori criteria and were included, yielding 59 unique quality indicator data points. Documentation and assessment quality indicators accounted for 64% of data points identified, clinical care for 25% and outcomes for 10%. An additional 53 'AFEM-CC quality indicators near match' publications were identified (38 new publications and 15 previously identified studies that contained additional 'near match' data), yielding 87 data points. CONCLUSIONS: Data relevant to African emergency care facility-based quality indicators are highly limited. Future publications on emergency care in Africa should be aware of, and conform with, AFEM-CC quality indicators to strengthen understanding of quality.

Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting.

OBJECTIVES: This project seeks to improve providers' practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention. DESIGN: We conduct a two-arm, controlled, mixed-methods, hybrid type II study. SETTING: This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa. INTERVENTIONS: We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites. OUTCOME MEASURES: We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model. RESULTS: 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (-1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99). CONCLUSIONS: In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

Defining measures of emergency care access in low-income and middle-income countries: a scoping review.

BACKGROUND: Over 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care. OBJECTIVES: We performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems. ELIGIBILITY CRITERIA: English language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described. SOURCE OF EVIDENCE: PubMed, Embase, Web of Science, CINAHL and the grey literature. CHARTING METHODS: A structured data extraction tool was used to identify and classify the number of 'unique' measures, and the number of times each unique measure was studied in the literature ('total' measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the 'Three Delay' model of seeking, reaching and receiving care, and the WHO's Emergency Care Systems Framework (ECSF). RESULTS: A total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care-inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%). CONCLUSIONS: Numerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.

Ordering Characteristics Predictive of Noncontrast CT Head Positivity in the Emergency Department.

RATIONALE AND OBJECTIVES: Recent decades have seen a steady increase in noncontrast head CT utilization in the emergency department with a concurrent rise in the practice of physician assistants (PAs) and nurse practitioners (NPs). The goal of this study was to identify ordering and patient characteristics predictive of positive noncontrast head CTs in the ED. We hypothesized NP/PAs would have lower positivity rates compared to physicians, suggestive of relative overutilization. MATERIALS AND METHODS: We retrospectively identified ED patients who underwent noncontrast head CTs at a single institution: a nonlevel 1 trauma center, during a 7-year period, recording examination positivity, ordering provider training/experience, and multiple additional ordering/patient attributes. Exam positivity was defined as any intracranial abnormality necessitating a change in acute management, such as acute hemorrhage, hydrocephalus, herniation, or worsening prior findings. RESULTS: 6624 patients met inclusion criteria. 4.6% (280/6107) of physician exams were positive while 3.7% (19/517) of NP/PA exams were positive; however, differences were not significant. Increasing provider experience was not associated with positivity. Attributes with increased positivity were patient age (p < 0.001), daytime exam (p < 0.05), and indications regarding malignancy (p < 0.001) or focal neurologic deficit (p = 0.001). Attributes with decreased positivity were indications of trauma (p < 0.001) or vertigo/dizziness (p < 0.05). CONCLUSION: We found no significant difference in rates of exam positivity between physicians and NP/PAs, even accounting for years of experience. This suggests increasing utilization of head CTs in the ED is not due to the increasing presence of NP/PAs, and may be reflective of general practice trends and clear diagnostic algorithms leading to head CT.

A systematic review of acute and emergency care interventions for adolescents and adults with severe acute respiratory infections including COVID-19 in low- and middle-income countries.

Background: Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients >10 years old with SARIs in LMICs. Methods: A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients >10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools. Results: 20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity. Conclusions: We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed. Registration: PROSPERO registration number: CRD42020216117.

Association of a Callback Program With Emergency Department Revisit Rates Among Patients Seeking Emergency Care.

Importance: The emergency department (ED) discharge process often involves haste and poor communication. Objectives: To assess the association of an automated telephone call 2 days after ED discharge with the likelihood of an unplanned ED revisit at both 72 hours and 7 days after the index visit and with perceived care metrics measured at 14 days. Design, Setting, and Participants: This prospective nonrandomized clinical trial was conducted at a single academically affiliated county emergency department among 8110 patients presenting to and discharged from the ED during a 10-week period from June 25 to August 30, 2018. Initial statistical analysis was performed from February 1 to November 30, 2020, with additional analyses performed from March 1 to 16, 2022. Interventions: Participants were allocated in a nonrandom fashion to 1 of 2 groups: patients who received an automated telephone call 2 days after discharge were compared with patients who received no call 2 days after discharge. All patients received a telephone questionnaire at 14 days to assess secondary outcome measures. Main Outcomes and Measures: The primary outcome was a return visit to the ED at 7 days. Secondary outcomes included a return visit to the ED within 72 hours, a return visit to the ED within 7 days resulting in hospital admission, and patient-reported perceptions of their care measured by 4 questions related to quality metrics assessed at 14 days. A secondary analysis compared patients who actually responded to the initial call at 2 days with all nonresponders, regardless of whether they received a call. Analyses were made on an intention-to-treat basis. Results: More than 15 000 patients were seen in the ED during the 10-week study period, and 10 948 were discharged. A total of 8110 patient encounters (4460 male patients [55.0%]; 3313 Hispanic patients [40.9%]; mean [SD] age, 40.5 [19.4] years) were enrolled. A total of 2958 patients (36.5%) received an automated telephone call at 2 days after discharge, while 5152 (63.5%) received no call. Rates of ED return within 7 days of the initial index visit were significantly lower among those who received a call at 2 days than those who did not receive a call (224 of 2958 [7.6%] vs 533 of 5152 [10.3%]; P < .001). Patients who received a 2-day call were more likely than those who did not receive a call to have followed up with a health care clinician (67.9% [374 of 551] vs 66.3% [604 of 911]), understood their health issues (77.5% [490 of 632] vs 74.9% [780 of 1042]), and have received their discharge medications (87.0% [507 of 583] vs 83.6% [793 of 949]), although none of these differences between the 2 groups were statistically significant. Conclusions and Relevance: A telephone call to patients 2 days after discharge from the ED was associated with decreased ED use at 7 days after the index visit and may have been associated with marginal improvements in measured quality of care metrics.

Climate change and emergency care in Africa: A scoping review.

Introduction: Climate change is a global public health emergency with implications for access to care and emergency care service disruptions. The African continent is particularly vulnerable to climate-related extreme weather events due to an already overburdened health system, lack of early warning signs, poverty, inadequate infrastructure, and variable adaptive capacity. Emergency care services are not only utilized during these events but also threatened by these hazards. Considering that the effects of climate change are expected to increase in intensity and prevalence, it is increasingly important for emergency care to prepare to respond to the changes in presentation and demand. The aim of this study was to perform a scoping review of the available literature on the relationship between climate change and emergency care on the African continent. Methods: A scoping review was completed using five databases: Pubmed, Web of Science, GreenFILE, Africa Wide Information, and Google Scholar. A 'grey' literature search was done to identify key reports and references from included articles. Two independent reviewers screened articles and a third reviewer decided conflicts. A total of 1,382 individual articles were initially screened with 17 meeting full text review. A total of six articles were included in the final analysis. Data from four countries were represented including Uganda, Ghana, Tanzania, and Nigeria. Results: Analysis of the six articles yielded three key themes that were identified: climate-related health impacts that contribute to surges in demand and resource utilization, opportunities for health sector engagement, and solutions to improve emergency preparedness. Authors used the outcomes of the review to propose 10 recommendations for decision-makers and leaders. DXDiscussion: Incorporating these key recommendations at the local and national level could help improve preparedness and adaptation measures in highly vulnerable, populated areas on the African continent.

Odds of return: a prospective study using provider assessment to predict short-term patient return visits to the emergency department.

OBJECTIVE: Previous studies have assessed patient-level characteristics associated with emergency department (ED) return visits, but none have used provider assessment. We prospectively investigate whether clinical providers could accurately predict ED return visits. METHODS: Prospective cohort study. SETTING: Single academically affiliated urban county hospital. PARTICIPANTS: Discharged ED patients over a 14-month period with a provider assessment of the likelihood of patient return within 7 days of ED discharge. MAIN OUTCOME MEASURES: The primary outcome of interest was a return visit to the ED within 7 days. Additional outcome measures included a return visit within 72 hours and a return visit resulting in admission. We also measured the accuracy of provider gestalt, and provide measures of sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: Of the 11 922 ED discharges included in this study, providers expected 2116 (17.7%) to result in a return visit within 7 days. Providers were much more likely to perceive a return visit if the patient left against medical advice (OR: 5.97, 95% CI: 4.67 to 7.62), or was homeless (OR: 5.69, 95% CI: 5.14 to 6.29). Patients who actually returned were also more likely to be homeless, English speaking and to have left the ED against medical advice on the initial encounter. The strongest predictor of a return visit at both 72 hours and 7 days in multivariable modelling was provider assessment (OR: 3.77, 95% CI: 3.25 to 4.37; OR: 3.72, 95% CI: 3.29 to 4.21, respectively). Overall sensitivity and specificity of provider gestalt as a measure of patient return within 7 days were 47% and 87%, respectively. The positive and negative likelihood ratios were 3.51 and 0.61, respectively. CONCLUSIONS: Clinician assessment was the strongest predictor of a return visit in this dataset. Clinician assessment may be used as a way to screen patients during the index visit and enrol them in efforts to decrease return visits.

Potential solutions for screening, triage, and severity scoring of suspected COVID-19 positive patients in low-resource settings: a scoping review.

OBJECTIVES: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring of patients with suspected COVID-19 on initial presentation to the healthcare system and to evaluate the utility of these tools in LRS. DESIGN: A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of patients with suspected COVID-19 published between 12 December 2019 and 1 April 2021. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. PARTICIPANT: The initial search strategy yielded 15 232 articles; 124 met inclusion criteria. RESULTS: Most studies were from China (n=41, 33.1%) or the United States (n=23, 18.5%). In total, 57 screening, 23 triage, and 54 severity scoring tools were described. A total of 51 tools-31 screening, 5 triage, and 15 severity scoring-were identified as feasible for use in LRS. A total of 37 studies provided validation data: 4 prospective and 33 retrospective, with none from low-income and lower middle-income countries. CONCLUSIONS: This study identified a number of screening, triage, and severity scoring tools implemented and proposed for patients with suspected COVID-19. No tools were specifically designed and validated in LRS. Tools specific to resource limited contexts is crucial to reducing mortality in the current pandemic.

The effects of mobile health on emergency care in low- and middle-income countries: A systematic review and narrative synthesis.

BACKGROUND: In resource-constrained settings, mobile health (mHealth) has varied applications. While there is strong evidence for its use in chronic disease management, the applications of mHealth for management of acute illness in low- and middle-income countries (LMICs) are not as well described. This review systematically explores current available evidence on the effectiveness of mHealth interventions at improving health outcomes in emergency care settings in LMICs. METHODS: A systematic search of the literature was performed in accordance with PRISMA guidelines, utilizing seven electronic databases and manual searches to identify peer-reviewed literature containing each of three search elements: mHealth, emergency care (EC), and LMICs. Articles quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: After removing duplicates, 6498 studies met initial search criteria; 108 were eligible for full text review and 46 met criteria for inclusion. Thirty-six pertained to routine emergency care, and 10 involved complex humanitarian emergencies. Based on the GRADE criteria, 15 studies were rated as "Very Low" quality, 24 as "Low" quality, 6 as "Moderate" quality, and 1 as "High" quality. Eight studied data collection, 9 studied decision support, 15 studied direct patient care, and 14 studied health training. All 46 studies reported positive impacts of mHealth on EC in LMICs. CONCLUSIONS: Mobile health interventions can be effective in improving provider-focused and patient-centered outcomes in both routine and complex EC settings. Future investigations focusing on patient-centered outcomes are needed to further validate these findings.

Qualitative needs assessment for paediatric emergency care in Kampala, Uganda.

INTRODUCTION: Acute childhood illnesses, such as malaria, pneumonia, and diarrhoea, represent the leading causes of under-five mortality in Uganda. Given that most early child deaths are treatable with timely interventions, emergency units dedicated to paediatric populations have been established in the country. In light of recent developments, the department of paediatrics at Makerere University requested a needs assessment in the paediatric acute care unit (PACU) at Mulago National Referral Hospital, which could guide the development of a new training curriculum for medical providers. METHODS: We administered a survey for medical providers working in the PACU at Mulago Hospital, which assessed their self-rated comfort levels with paediatric assessment, treatment, and teamwork skills. We also conducted focus groups with a smaller subset of medical providers to understand barriers and facilitators to paediatric emergency and critical care. RESULTS: Of 35 paediatric assessment, treatment, and teamwork skills, 29 (83%) questions had the median comfort rating of 6 or 7 on a 7-point Likert scale. The remaining 6 (17%) skills had a median comfort rating of 5 or lower. Focus groups identified a number of major barriers to caring for critically ill children, including limited resources and staffing, training gaps, and challenges with interprofessional teamwork. In terms of training development, focus group participants suggested continuous training for all medical providers working in the PACU led by local leaders. DISCUSSION: This study identified the need and desirability of continuous trainings in the PACU. Key components include objective skills assessment, simulation-based scenarios, and interprofessional teamwork. Training development should be augmented by increases in resources, staffing, and training opportunities in collaboration with the Uganda Ministry of Health.

Continuing Education for Prehospital Healthcare Providers in India - A Novel Course and Concept.

BACKGROUND: Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India. METHODS: From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide). LESSONS LEARNED: During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials. CONCLUSION: These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

Emergency Care Systems: The Missing Link for Effective Treatment of COVID-19 in Africa.

Cases of COVID-19 are rising quickly on the African continent. A critical element of any health system response to such a surge of active cases is the existence of functional emergency care systems. Yet, these systems are markedly underdeveloped in African countries. This short letter reviews the key role emergency medicine plays in epidemic disease response and actions that ministries of health can take now to shore up gaps in emergency care capacity to avoid needless death and suffering of COVID-19 patients.

Acute respiratory illness among a prospective cohort of pediatric patients using emergency medical services in India: Demographic and prehospital clinical predictors of mortality.

BACKGROUND: In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint. METHODS: Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality. RESULTS: A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days. CONCLUSIONS: This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.

A profile of traumatic injury in the prehospital setting in India: A prospective observational study across seven states.

BACKGROUND: Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population. METHODS: We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality. RESULTS: We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N = 2088), of lower economic status (97%, N = 2805 used a government issued ration card) and were from rural or tribal areas (74%, N = 2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)). CONCLUSIONS: EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study.

BACKGROUND: Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India. METHODS: We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables. RESULTS: We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2). DISCUSSION: Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services.

OBJECTIVES: To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. DESIGN: Prospective observational study. SETTING: Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014. PARTICIPANTS: Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded. MAIN OUTCOME MEASURES: death at 2, 7 and 42 days after delivery. RESULTS: Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality. CONCLUSIONS: The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country.

Introduction Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes. Problem This study aimed to characterize the referral and transfer systems in the largest county of Liberia. METHODS: A cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices. RESULTS: A total of 62 health facilities-41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)-were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities. CONCLUSION: This study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for referral exist and could serve as the basis for a more robust system. Well-integrated acute care referral systems in low-income countries, like Liberia, may help to mitigate future public health crises by augmenting a country's capacity for emergency preparedness. Kim J , Barreix M , Babcock C , Bills CB . Acute care referral systems in Liberia: transfer and referral capabilities in a low-income country. Prehosp Disaster Med. 2017;32(6):642-650.