Undernourished children presenting to an urban emergency department of a tertiary hospital in Tanzania: a prospective descriptive study.

BACKGROUND: Childhood undernutrition causes significant morbidity and mortality in low- and middle-income countries (LMICs). In Tanzania, the in-hospital prevalence of undernutrition in children under five years of age is approximated to be 30% with a case fatality rate of 8.8%. In Tanzania, the burden of undernourished children under five years of age presenting to emergency departments (EDs) and their outcomes are unknown. This study describes the clinical profiles and outcomes of this population presenting to the emergency department of Muhimbili National Hospital (ED-MNH), a large, urban hospital in Dar es Salaam, Tanzania. METHODS: This was a prospective descriptive study of children aged 1-59 months presenting to the ED-MNH over eight weeks in July and August 2016. Enrolment occurred through consecutive sampling. Children less than minus one standard deviation below World Health Organization mean values for Weight for Height/Length, Height for Age, or Weight for Age were recruited. Structured questionnaires were used to document primary outcomes of patient demographics and clinical presentations, and secondary outcomes of 24-h and 30-day mortality. Data was summarised using descriptive statistics and relative risks (RR). RESULTS: A total of 449 children were screened, of whom 34.1% (n = 153) met criteria for undernutrition and 95.4% (n = 146) of those children were enrolled. The majority of these children, 56.2% (n = 82), were male and the median age was 19 months (IQR 10-31 months). They presented most frequently with fever 24.7% (n = 36) and cough 24.0% (n = 35). Only 6.7% (n = 9) were diagnosed with acute undernutrition by ED-MNH physicians. Mortality at 24 h and 30 days were 2.9% (n = 4) and 12.3% (n = 18) respectively. A decreased level of consciousness with Glasgow Coma Scale below fifteen on arrival to the ED and tachycardia from initial vital signs were found to be associated with a statistically significant increased risk of death in undernourished children, with mortality rates of 16.1% (n = 23), and 24.6% (n = 35), respectively. CONCLUSIONS: In an urban ED of a tertiary referral hospital in Tanzania, undernutrition remains under-recognized and is associated with a high rate of in-hospital mortality.

Impact of short basic emergency medicine training in introducing emergency medicine as a specialty in Sub-Saharan Africa: experience from Tanzania.

BACKGROUND: Emergency medicine (EM) is a new specialty in Tanzania. Little is known about how to introduce EM to health care providers (HCPs) in hospitals without EM. We determined the impact of a 2-day EM training program on the understanding, perception, and choice of EM as a career amongst HCPs at hospitals in Tanzania without EM. METHODS: This was a pre- and post-training interventional study including randomly selected HCPs from four tertiary hospitals in Tanzania without EM. Understanding, perception, and desirability of EM as a career were assessed before and after a 2-day university-accredited basic EM short-course training given by EM physicians. A paper-based Likert scale (out of 5) questionnaire was used, which were analyzed by T tests, Mann-Whitney, and Kruskal-Wallis tests. RESULTS: During the study period, 96 health care providers (100% capture) in the four tertiary hospitals participated in the study. The median age of participants was 34 years (IQR 28-43); 35 (36.0%) were males. Sixty (63%) were nurses, 26 (27%) doctors, and 3 (3%) were administrators. The four hospitals were equally represented. Median pre-training scores for all Likert questions were 3.49 (IQR 3.3-3.9); understanding 3.3 (IQR 3.0-3.7), perception 3.40 (IQR 3.1-3.7), and career decision-making 3.7 (IQR 3.3-4.0). Post-training scores improved with median scores of 4.6 (IQR 4.5-4.7) overall, 4.7 (IQR 4.0-4.7) for understanding, 4.6 (IQR 4.5-4.9) for perception, and 4.7 (IQR 4.3-4.8) for career decision-making (all p < 0.01). CONCLUSION: A 2-day training in basic EM care had a positive impact on understanding, perception, and career decisions regarding EM amongst Tanzania HCPs that work in hospitals without EM. Follow-up to assess long-term impact, and expansion of this program, is recommended to foster EM in countries where this is a new specialty.

Modified systemic inflammatory response syndrome and provider gestalt predicting adverse outcomes in children under 5 years presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Modified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. However, this has not been studied in low-income countries. We investigated the ability of mSIRS and provider gestalt to predict mortality and morbidity among children presenting to the ED of a tertiary level hospital in Tanzania. METHODS: This prospective observational study enrolled a convenience sample of children under 5 years old, presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2015 to April 2016. Trained researchers used a structured case report form to record patient demographics, clinical presentation, initial provider gestalt of severity of illness, and the mSIRS criteria. Primary outcomes were 24-h mortality and overall in-hospital mortality. Data was analyzed using simple descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and chi-squared tests. RESULTS: We enrolled 1350 patients, median age 17 months (interquartile range 8-32 months), and 58% were male. Provider gestalt estimates of illness severity were recorded for all patients and 1030 (76.3%) had complete data for mSIRS categorization. Provider gestalt classified 97 (7.2%) patients as healthy, 546 (40.4%) as mildly ill, 457 (33.9%) as moderately ill, and 250 (18.5%) as severely ill. Of the patients, classifiable by mSIRS, 411/1030 (39.9%) had ≥ 2 mSIRS criteria. In predicting 24-h mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 82% and 81%, respectively, and specificity of 61% and 84%, respectively. In predicting overall in-hospital mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 66% and 70% with a specificity of 62% and 86% respectively. CONCLUSION: Both the mSIRS and provider gestalt were highly specific for predicting 24-h and overall in-hospital mortality in our patient population. The clinical utility of these assessment methods is limited by the low positive predictive value.

The prevalence of alcohol and illicit drug use among injured patients presenting to the emergency department of a national hospital in Tanzania: a prospective cohort study.

BACKGROUND: Alcohol and illicit drugs have been found to be major contributing factors leading to severe injuries in a variety of settings. In Tanzania, the use of these substances among injured patients has not been studied. We investigated the prevalence of positive tests for alcohol and illicit drug use among injured patients presenting to the emergency medicine department (ED) of Muhimbili National Hospital (MNH). METHODS: This was a prospective cohort study of a consecutive sample of patients > 18 years of age presenting to the ED-MNH with injury related complaints in October and November 2015. A structured data sheet was used to record demographic information, mechanism of injury, clinical presentation, alcohol and illicit drug test results, and ED disposition. Alcohol levels and illicit drug use were tested by breathalyser device or swab stick alcohol test and multidrug urine panel, respectively. Patients were followed up for 24 h and 30 days using medical chart reviews and phone calls. Descriptive statistics and relative risk were used to describe the results. RESULTS: We screened 1011 patients and we enrolled all 143 (14.1%) patients who met inclusion criteria. 123 (86.0%) were male, the median age was 30 years (IQR: 23-36 years). The most frequent mechanism of injury was road traffic accidents (84.6%). 67/143 (46.9%) patients tested positive for alcohol and 44/122 (36.1%) patients tested positive for drugs. 29 (26.1%) tested positive for alcohol and drugs. The most frequently detected illicit drug was marijuana in 30/122 (24.5%) injured patients. 23/53 (43.4%) patients with positive alcohol testing self-reported alcohol use. 3/25 patients with positive illicit drug tests who were able to provide self-reports, self-reported drug use. At 30-day followup, 43 (64.2%) injured patients who tested positive for alcohol had undergone major surgery, 6 (9.0%) had died, and 36 (53.7%) had not yet returned to their baseline. CONCLUSIONS: The prevalence of alcohol and illicit drugs is very high in patients presenting to the ED-MNH with injury. Further studies are needed to generalise the results in Tanzania. Public health initiatives to decrease drinking and/or illicit drug use and driving should be implemented.

Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study.

BACKGROUND: Tanzania has witnessed several disasters in the past decade, which resulted in substantial mortality, long-term morbidity, and significant socio-economic losses. Health care facilities and personnel are critical to disaster response. We assessed the current state of disaster preparedness and response capacity among Tanzanian regional hospitals. METHODS: This descriptive cross-sectional survey was conducted in all Tanzanian regional hospitals between May 2012 and December 2012. Data were prospectively collected using a structured questionnaire based on the World Health Organization National Health Sector Emergency Preparedness and Response Tool. Trained medical doctors conducted structured interviews and direct observations in each hospital. RESULTS: We surveyed 25 regional hospitals (100% capture) in mainland Tanzania, in which interviews were conducted with 13-hospital doctors incharge, 9 matrons and 4 heads of casualty. All the hospitals were found to have inadequate numbers of all cadres of health care providers to support effective disaster response. 92% of hospitals reported experiencing a disaster in the past 5 years; with the top three being large motor vehicle accidents 22 (87%), floods 7 (26%) and infectious disease outbreaks 6 (22%). Fifteen hospitals (60%) had a disaster committee, but only five (20%) had a disaster plan. No hospital had all components of surge capacity. Although all had electricity and back-up generators, only 3 (12%) had a back-up communication system. CONCLUSION: This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters.

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. METHODS: This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. RESULTS: We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. CONCLUSION: In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

The Burden and Outcomes of Abdominal Pain among Children Presenting to an Emergency Department of a Tertiary Hospital in Tanzania: A Descriptive Cohort Study.

BACKGROUND: Abdominal pain in children can represent benign conditions or life-threatening emergencies. Aetiologies of paediatric abdominal pain vary geographically and have not been studied in acute care settings in East Africa. This study describes the clinical profiles and outcomes of children presenting with undifferentiated abdominal pain to the Emergency Department of Muhimbili National Hospital (ED-MNH). METHODS: This was a prospective cohort study of children below 18 years of age presenting to the ED-MNH with abdominal pain. A structured case report form was used to collect data on patients from June to December 2016. Data included demographics, clinical presentation, and mortality. Data were summarised using descriptive statistics. RESULTS: Out of 1855 children who presented to ED-MNH, 184 (9.9%) met inclusion criteria, and all were enrolled. The median age was 3.5 years (IQR: 1.3-7.0 years) and 124 (67.4%) were male. Most (138 [75.0%]) were referred from peripheral hospitals. The most frequent ED providers' diagnoses were hernia (34 [18.5%]) and intra-abdominal malignancy (19 [10.3%]). From the ED, 37 (20.1%) were discharged home, 83 (45.1%) were admitted to medical wards, and 48 (26.1%) were admitted to surgical wards. 16 (8.7%) underwent an operation. 24-hour, seven-day, and three-month mortality rates were 1.1%, 6.5%, and 14.5%, respectively. The overall in-hospital mortality rate was 12.2%. Multivariate analysis showed that age below 5 years, female sex, and haemoglobin less than 10.9 g/dl were significant factors associated with in-hospital mortality. DISCUSSION AND CONCLUSION: Abdominal pain is a common complaint among paediatric patients presenting to the ED-MNH. This presentation was associated with a high admission rate and a high mortality rate. Age below 5 years, female sex, and haemoglobin less than 10.9 g/dl were associated with mortality. Further studies and quality improvement efforts should focus on identifying aetiologies, risk stratification, and appropriate interventions to optimise patients outcomes.

Emergency blood transfusion practices among anaemic children presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Severe anaemia contributes significantly to mortality, especially in children under 5 years of age. Timely blood transfusion is known to improve outcomes. We investigated the magnitude of anaemia and emergency blood transfusion practices amongst children under 5 years presenting to the Emergency Department (ED) of Muhimbili National Hospital (MNH) in Tanzania. METHODS: This prospective observational study enrolled children under 5 years old with anaemia, over a 7-week period in August and September of 2015. Anaemia was defined as haemoglobin of <11 g/dL. Demographics, anaemia severity, indications for transfusion, receipt of blood, and door to transfusion time were abstracted from the charts using a standardized data entry form. Anaemia was categorized as severe (Hb <7 g/dL), moderate (Hb 7-9.9 g/dL) or mild (Hb 10-10.9 g/dL). RESULTS: We screened 777 children, of whom 426 (55%) had haemoglobin testing. Test results were available for 388/426 (91%), 266 (69%) of whom had anaemia. Complete data were available for 257 anaemic children, including 42% (n = 108) with severe anaemia, 40% (n = 102) with moderate anaemia and 18% (n = 47) with mild anaemia. Forty-nine percent of children with anaemia (n = 125) had indications for blood transfusion, but only 23% (29/125) were transfused in the ED. Among the non-transfused, the provider did not identify anaemia in 42% (n = 40), blood was not ordered in 28% (n = 27), and blood was ordered, but not available in 30% (n = 29). The median time to transfusion was 7.8 (interquartile range: 1.9) hours. Mortality was higher for the children with severe anemia who were not transfused as compared with those with severe anaemia who were transfused (29% vs 10%, p = 0.03). CONCLUSION: The burden of anaemia is high among children under 5 presenting to EMD-MNH. Less than a quarter of children with indications for transfusion receive it in the EMD, the median time to transfusion is nearly 8 h, and those not transfused have nearly a 3-fold higher mortality. Future quality improvement and research efforts should focus on eliminating barriers to timely blood transfusion.

Trauma burden in Tanzania: a one-day survey of all district and regional public hospitals.

BACKGROUND: Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies. METHODS: This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported. RESULTS: A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22-35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas. CONCLUSIONS: Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

Patients with acute poisoning presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Poisoning is a major public health concern in sub-Saharan Africa, affecting patients of all age groups. Poisoned patients often present to the emergency department (ED) and prompt evaluation and appropriate management are imperative to ensure optimal outcomes. Unfortunately, little is known about the specific presentations of poisoned patients in East Africa. We describe the clinical and epidemiological features of patients presenting to the Muhimbili National Hospital (MNH) ED with suspected toxicological syndromes. METHODS: This prospective study enrolled a consecutive sample of ED patients who presented with a suspected toxicological syndrome from March 2013 to June 2013. Trained investigators completed a structured case report form (CRF) for each eligible patient, documenting the suspected poison, demographic information, the clinical presentation, and the ED outcome and disposition. The study data were analyzed and summarized with descriptive statistics. RESULTS: Of 8827 patients, who presented to ED-MNH, 106 (1.2%) met inclusion criteria, and all were enrolled. Among those enrolled, the median age was 28 years (interquartile range [IQR] 16 years), and 81 (76.4%) were male. Overall 55 (52%) were single, and 28 (26.4%) had professional jobs. 60 (56.6%) patients were referred from district hospitals, 86.8% of which were in Dar es Salaam. Only 13 (12.3%) of patients presented to the ED within 2 h of the toxic exposure. The etiology of poisoning included alcohol in 42 (50%), a mixture of different medications in 12 (14.3%), and snakebite in 6 (11.3%). Most exposures were intentional (63 [59.4%]) and were via the oral route (88 [83%]). The most common abnormal physical findings were altered mental status (66 [62.3%]) and tachypnoea (68 [64.2%]). One patient died in the ED and 98 (92.5%) required hospital admission. CONCLUSIONS: Most patients presenting to the ED with a toxicological syndrome were adult males with intentional exposures. The most common toxic exposure was alcohol (ethanol) intoxication and the most common abnormal findings were altered mental status and tachypnoea. More than three-quarter of patients presented after 2 h of exposure. Almost all patients were admitted to the hospital.

Predicting Fluid Responsiveness Using Bedside Ultrasound Measurements of the Inferior Vena Cava and Physician Gestalt in the Emergency Department of an Urban Public Hospital in Sub-Saharan Africa.

BACKGROUND: Bedside inferior vena cava (IVC) ultrasound has been proposed as a non-invasive measure of volume status. We compared ultrasound measurements of the caval index (CI) and physician gestalt to predict blood pressure response in patients requiring intravenous fluid resuscitation. METHODS: This was a prospective study of adult emergency department patients requiring fluid resuscitation. A structured data sheet was used to record serial vital signs and the treating clinician's impression of patient volume status and cause of hypotension. Bedside ultrasound CI measurements were performed at baseline and after each 500mL of fluid. Receiver operating characteristic (ROC) curve analysis was performed to characterize the relationship between CI and Physician gestalt, and the change in mean arterial pressure (MAP). RESULTS: We enrolled 364 patients, 52% male, mean age 36 years. Indications for fluid resuscitation were haemorrhage (54%), dehydration (30%), and sepsis (17%). Receiver operating characteristic curve analysis found optimal CI cut-off values of 45%, 52% and 53% to predict a MAP rise of 5, 8 and 10 mmHg per litre of fluid, respectively. The sensitivity and specificity of CI of 50% for predicting a 10mmHg increase in MAP per litre were 88% (95%CI 81-93%) and 73% (95%CI 67-79%), respectively, area under the curve (AUC) = 0.85 (0.81-0.89). The sensitivity and specificity of physician gestalt estimate of volume depletion severity were 68% (95%CI 60-75%) and 86% (95%CI 80-90%), respectively, AUC = 0.83 (95% CI: 0.79-0.87). Those with a baseline CI ≥ 50% (51% of patients) had a 2.8-fold greater fluid responsiveness than those with a baseline CI<50% (p<0.0001). CONCLUSION: Ultrasound measurement of the CI can predict blood pressure response among patients requiring intravenous fluid resuscitation and may be useful in early identification of patients who will benefit most from volume resuscitation, and those who will likely require other interventions.

HIV counselling and testing practices for children seen in an urban emergency department of a tertiary referral hospital in Dar es Salaam, Tanzania: a retrospective cross-sectional study.

OBJECTIVES: To describe the HIV counselling and testing practices for children presenting to an emergency department (ED) in a low-income country. SETTING: The ED of a large east African national referral hospital. PARTICIPANTS: This retrospective review of all paediatric (<18 years old) ED visits in 2012 enrolled patients who had an HIV test ordered and excluded those without testing. Files were available for 5540/5774 (96%) eligible patients and 1632 (30%) were tested for HIV, median age 1.3 years (IQR 9 months to 4 years), 58% <18 months old and 61% male. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was documentation of pretest and post-test counselling, or deferral of counselling, for children tested for HIV in the ED. Secondary measures included the overall rate of HIV testing, rate of counselling documented in the inpatient record when deferred in the ED, rate of counselling documented when testing was initiated by the inpatient service, rate of counselling documented by test result (positive vs negative) and the rate of referral to follow-up HIV care among patients testing positive. RESULTS: Of 418 patients tested in the ED, counselling, or deferral of counselling, was documented for 70 (17%). When deferred to the ward, subsequent counselling was documented for 15/42 (36%). Counselling was documented in 33% of patients testing positive versus 1.1% patients testing negative (OR 43 (95% CI 23 to 83). Of 199 patients who tested positive and survived to hospital discharge, 76 (38%) were referred for follow-up at the HIV clinic on discharge. CONCLUSIONS: Physicians documented the provision, or deferral, of counselling for <20% of children tested for HIV in the ED. Counselling was much more likely to be documented when the test result was positive. Less than 40% of those testing positive were referred for follow-up care.

The test characteristics of physician clinical gestalt for determining the presence and severity of anaemia in patients seen at the emergency department of a tertiary referral hospital in Tanzania.

OBJECTIVES: To evaluate the test characteristics of clinical gestalt for detecting the presence and severity of anaemia in emergency department patients at a tertiary referral hospital in Tanzania. METHODS: This prospective study enrolled a convenience sample of emergency department patients who had a complete blood count ordered by the treating physician in the course of their clinical care. Physicians recorded their impression of the presence and severity of anaemia before viewing the laboratory results. To assess interobserver agreement, a second physician provided their blinded gestalt impression of the patient's haemoglobin level. RESULTS: We enrolled 216 patients and complete data were available for 210 patients (97%), 59% male, median age 30 years. The range of measured haemoglobin values was 1.5-15.4 g/dL. The physicians rated anaemia mild or absent in 74 (35%), moderate in 72 (34%) and severe in 64 patients (30%). These estimates were significantly concordant with the laboratory haemoglobin measurements (Kendall's τ b=0.63, 95% CI 0.57 to 0.69, p<0.0001). The test characteristics of physician gestalt estimates for severe anaemia were: sensitivity 64% (95% CI 53% to 74%), specificity 91% (95% CI 85% to 96%), positive likelihood ratio of 7.4 (95% CI 4.2 to 13.3) and negative likelihood ratio of 0.40 (0.3 to 0.5). The weighted Cohen's κ for interobserver agreement between physicians on the gestalt estimate of the degree of anaemia was 0.87 (95% CI 0.76 to 0.98). CONCLUSION: Physicians' estimates of the severity of anaemia were significantly concordant with laboratory haemoglobin measurements. Sensitivity of the gestalt estimate for severe anaemia was moderate. Interobserver agreement was 'almost perfect'.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico.

INTRODUCTION: In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives. METHODS: We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications. RESULTS: Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation. DISCUSSION: Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.

INTRODUCTION: Dans les contextes riches en ressources, l'échographie au chevet du patient a rapidement évolué pour devenir un élément essentiel de la pratique en centre d'urgence et un élément d'importance croissante de la pratique des soins de courte durée. Cette technologie portable et abordable peut être encore plus précieuse dans des environnements limités en ressources où d'autres modes d'imagerie sont inaccessibles, mais la quantité optimale de formation nécessaire pour atteindre une compétence suffisante en échographie au chevet du patient est largement inconnue. Nous avons cherché à évaluer la faisabilité de la mise en œuvre d'un cours de formation en échographie au chevet du patient à modes mixtes pour les médecins de soins de courte durée d'urgence et généralistes dans un contexte aux ressources limitées, et à fournir une description des composantes de notre cours fondamental, notamment en termes d'objectifs de performance spécifiques, afin de faciliter la mise en œuvre d'initiatives similaires. MÉTHODES: Nous avons effectué un stage de formation normalisé sur deux sites distincts - un grand hôpital urbain tertiaire en Tanzanie équipé d'un Centre d'urgence dédié, et un petit hôpital rural au sud du Mexique ayant une zone d'admission de soins généraux intensifs. Nous établissons un rapport sur l'utilisation de l'échographie en pré-formation sur les deux sites, ainsi que sur les avis formulés avant et après la formation à propos des indications les plus utiles. RÉSULTATS: Dans l'ensemble, les participants étaient très satisfaits du cours, bien qu'environ un tiers des fournisseurs sur les deux sites auraient préféré plus de formation pratique. Tous les participants ont réussi un examen normalisé requérant une acquisition et une interprétation d'images. DISCUSSION: La fourniture d'une formation en échographie au chevet des patients dans deux contextes distincts aux ressources limitées était faisable et bien reçue. Après une brève période intensive de formation, les participants ont réussi un examen complet, incluant notamment la démonstration de l'acquisition d'image normalisée et de l'interprétation exacte d'études normales et anormale.

Trends in mortality associated with opening of a full-capacity public emergency department at the main tertiary-level hospital in Tanzania.

BACKGROUND: Emergency medicine is an emerging specialty in Sub-Saharan Africa, and most hospitals do not have a fully functional emergency department (ED). We describe the mortality rates of the Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania before and after the opening of a full-capacity ED. METHODS: This retrospective study investigated ED and hospital mortality rates for patients admitted to MNH from January 2008 to January 2012. This period represents 2 years before and 2 years after the opening of the full-capacity ED in January 2010. Trained abstractors analyzed patient care logbooks, attendance registers, nurse report books, and death certificates. The January 2008 to December 2009 data are from the limited-capacity casualty room (precursor of the ED), and for February 2010 to January 2012, they are from the new ED. Data are presented as proportions or differences with 95 % confidence intervals (CIs). RESULTS: During the 4-year study period, the number of visits increased from 53,660 (January 2008 to December 2009) in the casualty room to 77,164 (February 2010 to January 2012) in the new ED. During this time, the overall hospital mortality rate decreased from 13.6 % (95 % CI 13.3-13.9 %) in the January 2008 to December 2009 period to 8.2 % (95 % CI 8.0-8.3 %) in the February 2010 to January 2012 period. The corresponding casualty room and ED mortality rates were 0.34 % (95 % CI 0.25-0.35 %) and 0.74 % (95 % CI 0.68-0.80 %), respectively. In the casualty room, the most commonly reported cause of death was lower respiratory tract infection and least common was poisoning. In the new ED, the most commonly reported cause of death was congestive cardiac failure and the least common was cancer. CONCLUSIONS: The opening of a full-capacity ED in a tertiary-level hospital in sub-Saharan Africa was associated with a significant decrease in hospital mortality. This is despite a small, but significant, increase in the mortality rate in the ED as compared to that in the casualty room that it replaced.

Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania.

BACKGROUND: In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania. METHODS: This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC). RESULTS: MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009-2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%. CONCLUSIONS: The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.

Emergency and critical care services in Tanzania: a survey of ten hospitals.

BACKGROUND: While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty. METHODS: Ten hospitals in four regions of Tanzania were assessed using a structured data collection tool. Quality was evaluated with standards developed from the literature and expert opinion. RESULTS: Important deficits were identified in infrastructure, routines and training. Only 30% of the hospitals had an emergency room for adult and paediatric patients. None of the seven district and regional hospitals had a triage area or intensive care unit for adults. Only 40% of the hospitals had formal systems for adult triage and in less than one third were critically ill patients seen by clinicians more than once daily. In 80% of the hospitals there were no staff trained in adult triage or critical care. In contrast, a majority of equipment and drugs necessary for emergency and critical care were available in the hospitals (median 90% and 100% respectively. The referral/private hospitals tended to have a greater overall availability of resources (median 89.7%) than district/regional hospitals (median 70.6). CONCLUSIONS: Many of the structures necessary for Emergency and Critical Care are lacking in hospitals in Tanzania. Particular weaknesses are infrastructure, routines and training, whereas the availability of drugs and equipment is generally good. Policies to improve hospital systems for the care of emergency and critically ill patients should be prioritised.

Emergency care capacity in Africa: a clinical and educational initiative in Tanzania.

Even though sub-Saharan Africa faces a disproportionate burden of acute injury and illness, few clinical facilities are configured to take an integrated approach to resuscitation and stabilization. Emergency care is a high-impact and cost-effective form of secondary prevention; disease surveillance at facilities delivering acute and emergency care is essential to guide primary prevention. Barriers to emergency care implementation in the region include limited documentation of the acute disease burden, a lack of consensus on regionally appropriate metrics to facilitate impact evaluation, and the lack of coordinated advocacy for acute disease prevention and emergency care. Despite these challenges, interest in creating dedicated acute care facilities and emergency training programs is rapidly expanding in Africa. We describe one such initiative at Muhimbili National Hospital in Dar es Salaam, with a focus on the development of the emergency medicine residency program.