ABSTRACT
BACKGROUND: Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and remain a key target population for efforts to reduce transmission. While HIV prevention tools such as PEP and PrEP are available through outpatient FSW clinics, these services are underused. Emergency medicine is a rapidly expanding field in Kenya and may provide a novel venue for initiating or optimizing HIV prevention services. This study examined the characteristics of FSW from Nairobi, Kenya, who had utilized an emergency department (ED) during the past year to broaden our understanding of the patient factors related to usage. METHODS: An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019. The participants were categorized into those who attended an ED over the past year (acute care users) and clinic-only users (control). A modified version of the WHO Violence Against Women Instrument assessed gender-based violence. Multivariable negative binomial logistic regressions evaluated predictors of health care use among these populations. RESULTS: Of the total 220 women (median [IQR] age 32 [27-39]), 101 and 116 were acute care and control populations, respectively. Acute care users had 12.7 ± 8.5 healthcare visits over a 12-month period, and the control population had 9.1 ± 7.0 (p < 0.05). ED attendance did not improve the PrEP usage, with 48.5%, and 51% of acute care and clinic users indicated appropriate PrEP use. Patient factors that correlated with health care utilization among acute care users included client sexual violence (OR 2.2 [1.64-2.94], p < 0.01), PrEP use (OR 1.54 (1.25-1.91), < 0.01), and client HIV status (OR 1.35 (1.02-1.69), p < 0.01). CONCLUSIONS: Many FSW at high risk for HIV were not accessing HIV prevention tools despite attending a dedicated FSW clinic offering such services. FSW who had attended an ED over the past year had a higher prevalence of HIV risk factors, demonstrating that emergency departments may be important acute intervention venues to prevent HIV transmission in this population. These results can guide policy design, health care provider training, and facility preparedness to support strategies aimed at improving HIV prevention strategies for FSW in Kenyan ED's.
ABSTRACT
OBJECTIVE: Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS: A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS: Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION: This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.
