The preventability of trauma-related death at a tertiary hospital in Ghana: a multidisciplinary panel review approach.

INTRODUCTION: The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency. METHOD: This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP). RESULTS: 1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%-66.3%). CONCLUSION: Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review.

Skill and knowledge retention after training in cardiopulmonary ultrasound in Ghana: an impact assessment of bedside ultrasound training in a resource-limited setting.

OBJECTIVE: Brief training courses in bedside ultrasound are commonly done by visiting faculty in low-income and middle-income countries, and positive short-term effects have been reported. Long-term outcomes are poorly understood. We held a training course on a cardiopulmonary ultrasound (CPUS) protocol over two separate 10-day periods in 2016. In 2017, 9-11 months after the initial training, we assessed skill and knowledge retention as well as perceived impact on local practice. METHODS: A written test using six clinical vignettes and an observed structured clinical examination were used to assess theoretical knowledge and practical skills. Additionally, in-person interviews and a written survey were completed with the physicians who had participated in the initial training. RESULTS: All 20 participants passed the written and clinical examination. The median follow-up test score was 10 out of 12, compared with a median score of 12 on a test completed immediately after the initial training. Physicians identified the ability to narrow their differential diagnosis and to initiate critical interventions earlier than without ultrasound as a key benefit of the CPUS training. They rated the cardiac, abdominal and inferior vena cava components of the CPUS protocol as most relevant to their everyday practice. CONCLUSION: Long-term ultrasound knowledge and skill retention was high after a brief and intensive training intervention at an academic tertiary hospital in Ghana. Clinicians reported improvements in patient care and local practice patterns.

An evidence-based approach to evaluation and management of the febrile child in Indian emergency department.

Fever is the most common complaint for a child to visit hospital. Under the aegis of INDO-US Emergency and Trauma Collaborative, Pediatric Emergency Medicine chapter of Academic College of Emergency Experts in India developed evidence-based consensus for evaluation and management of febrile child in emergency department. An extensive literature search and further online communication of the group led to the development of a detailed approach for the evaluation and management of individual conditions associated with fever. To develop an approach to individual conditions presenting with fever, that is, best suited to the epidemiology prevalent in India. The algorithmic approach given by the group describes in details the evaluation and management of specialized and individual conditions like fever and immunocompromised state, fever with localizing signs that include fever with seizures, cough, ear discharge, loose stools, rash and dysuria; fever without localization with epidemiological evidence supporting diagnosis such as malaria, enteric fever and dengue; and fever without any localization and no epidemiological evidence supporting the diagnosis.

Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial.

OBJECTIVE: To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting. METHODS: Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. RESULTS: Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups. CONCLUSIONS: In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience.

BACKGROUND: Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available. OBJECTIVES: To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC. METHODS: We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session. RESULTS: The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE. CONCLUSION: A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.

The role of short-term volunteers in a global health capacity building effort: the Project HOPE-GEMC experience.

BACKGROUND: Increasingly, medical students and practicing clinicians are showing interest in traveling to low-income settings to conduct research and engage in clinical rotations. While global health activities have the potential to benefit both the individual and the host, there can be challenges. We describe one way to harmonize the desire of volunteers to have a meaningful impact on the health care delivery system in a developing country with the needs of that country. METHODS: The Project Health Opportunities for People Everywhere (HOPE)-Ghana Emergency Medicine Collaborative (GEMC) Partnership has successfully integrated short-term volunteer physicians and nurses to facilitate the training of emergency medicine (EM) residents and specialist nurses in Kumasi, Ghana. RESULTS: Since the launching of this partnership in 2011, eight physicians and 10 nurses have rotated at Komfo Anokye Teaching Hospital (KATH). The impact of these volunteers goes beyond the clinical service and supervision they provide while on the ground. They act as mentors to the trainees and assist the program leadership with teaching and assessments. CONCLUSIONS: Although generally smooth, there have been challenges, all of which have been met and are being resolved. This partnership is an example of how collaborations can harness the expertise and energy of short-term volunteers to achieve the goals of capacity building and self-sustainability.

Optimizing clinical operations as part of a global emergency medicine initiative in Kumasi, Ghana: application of Lean manufacturing principals to low-resource health systems.

BACKGROUND: Although many global health programs focus on providing clinical care or medical education, improving clinical operations can have a significant effect on patient care delivery, especially in developing health systems without high-level operations management. Lean manufacturing techniques have been effective in decreasing emergency department (ED) length of stay, patient waiting times, numbers of patients leaving without being seen, and door-to-balloon times for ST-elevation myocardial infarction in developed health systems, but use of Lean in low to middle income countries with developing emergency medicine (EM) systems has not been well characterized. OBJECTIVES: To describe the application of Lean manufacturing techniques to improve clinical operations at Komfo Anokye Teaching Hospital (KATH) in Ghana and to identify key lessons learned to aid future global EM initiatives. METHODS: A 3-week Lean improvement program focused on the hospital admissions process at KATH was completed by a 14-person team in six stages: problem definition, scope of project planning, value stream mapping, root cause analysis, future state planning, and implementation planning. RESULTS: The authors identified eight lessons learned during our use of Lean to optimize the operations of an ED in a global health setting: 1) the Lean process aided in building a partnership with Ghanaian colleagues; 2) obtaining and maintaining senior institutional support is necessary and challenging; 3) addressing power differences among the team to obtain feedback from all team members is critical to successful Lean analysis; 4) choosing a manageable initial project is critical to influence long-term Lean use in a new environment; 5) data intensive Lean tools can be adapted and are effective in a less resourced health system; 6) several Lean tools focused on team problem-solving techniques worked well in a low-resource system without modification; 7) using Lean highlighted that important changes do not require an influx of resources; and 8) despite different levels of resources, root causes of system inefficiencies are often similar across health care systems, but require unique solutions appropriate to the clinical setting. CONCLUSIONS: Lean manufacturing techniques can be successfully adapted for use in developing health systems. Lessons learned from this Lean project will aid future introduction of advanced operations management techniques in low- to middle-income countries.