Emergency medical services (EMS) infrastructure development and operations in low- and middle-income countries: Formal, professional-driven (Tier-2) systems.

The World Health Organization recognized timely healthcare as a human right and called for the expansion of two-tiered prehospital and out-of-hospital emergency care systems in low- and middle-income countries. Tier-1 systems involve community-based first responder care, and Tier-2 systems involve more formalized emergency medical services designed as a sustainable system of services, including dedicated ambulances, personnel, and equipment. Tier-2 systems can play a crucial role in reducing mortality and disability due to emergency medical and surgical conditions worldwide. However, the implementation and operation of robust Tier-2 systems in low- and middle-income countries face significant challenges. This article examines the current state, challenges, and opportunities of Tier-2 system development and operations in low- and middle-income countries, highlighting the limited coverage and resourcing of existing systems. The challenges faced in developing Tier-2 systems in low- and middle-income countries include a lack of global awareness, financial constraints, regulatory and planning issues, cultural appropriateness, and workforce shortages. Additionally, the availability and maintenance of equipment, technology, transportation, facilities, and interfacility transfers pose significant hurdles. Localized adaptation of emergency medical services models to suit the diverse contexts of different low- and middle-income countries is critical, as are community partnerships in navigating the complexities of specific communities. Furthermore, Tier-2 systems in low- and middle-income countries should prioritize alignment with national policies and integration into their broader healthcare systems. There is also a need for innovative financial sustainability approaches, such as private-public partnerships and cost-sharing schemes, to overcome the upfront costs of establishing Tier-2 system infrastructure. Additionally, strategies for strengthening the emergency medical services workforce, including targeted recruitment and training, are explored. By addressing these challenges and opportunities, Tier-2 systems in low- and middle-income countries can better operate within their available resources and potentially contribute to improved healthcare outcomes. The sharing of best practices and collaborative networks between systems in low- and middle-income countries will also be critical for the development of Tier-2 system infrastructure in these areas.

Education and training of prehospital first responders in low- and middle-income countries.

Prehospital emergency medical services play a vital role in providing essential emergency medical and trauma care. However, in many low- and middle-income countries, there is a significant lack of adequate emergency medical services coverage, a problem compounded by a profound deficit of first responder training programs. The African Federation of Emergency Medicine classifies prehospital emergency care into 2 categories: tier-1, which includes laypersons, and tier-2, consisting of professionals equipped with dispatch capabilities. Both tier-1 and tier-2 first responders require protocolized training, integration, and coordination to varying degrees, with tier-1 programs focusing primarily on immediate stabilization and hospital transportation and tier-2 programs dedicating increased focus toward formal dispatch and advanced life support interventions. Training for both tiers of emergency medical services typically involves in-person didactic lectures with practical skills sessions. However, the content of these courses is highly context-dependent, and there is no international consensus regarding pedagogical methods or curriculum content for first responder training in low- and middle-income countries. Similarly, there is a lack of consensus in monitoring and evaluating training programs, including assessment methods, passing scores, and certification requirements. Although many programs use knowledge or skills acquisition testing, the content and depth of these examinations vary greatly, and long-term follow-up reporting is limited. As such, the educational landscape of both tier-1 and tier-2 emergency medical services in low- and middle-income countries remains highly varied and often faces a dual challenge of lacking clear international guidelines while still maintaining local appropriateness. Modular curricula developed in conjunction with standardized needs assessments, accompanied by the adoption of the training of trainers model, may present a pathway for local adaptability by leveraging local community members to inform and proliferate training. Although there have been notable improvements in prehospital training programs in resource-limited settings during the past 3 decades, challenges related to maintaining fidelity in monitoring and evaluation, expanding programs within resource constraints, and adapting to specific contexts continue to offer opportunities for further development in the future.

Evaluating a digital hybrid training-of-trainers (TOT) approach for lay first responder trauma education in urban Nigeria during the COVID-19 pandemic.

INTRODUCTION: Road traffic injuries (RTIs) are the largest contributor to the global burden of injury, and in 2016 were among the five leading causes of global disability-adjusted life years (DALYs). In regions with limited emergency medical services (EMS), training lay first responders (LFRs) has been shown to increase availability of prehospital care for RTIs, but sustainable mechanisms to scale these programs remain unstudied. METHODS: Using a training of trainers (TOT) model, a 5.5-h LFR training program was launched in Lagos, Nigeria. The course was taught in a hybrid fashion with primary didactics using videoconferencing software and practical breakout sessions in-person concurrently. Thirty TOTs proceeded to train 350 transportation providers as LFRs over one month. A 23-question, pre- and post-assessment was administered digitally to assess knowledge acquisition. Participants responded to a five-point Likert survey assessing instruction quality and post-course confidence. RESULTS: TOTs scored a median of 56.5 % (IQR:43.5 %,71.7 %) and 91.3 % (IQR:88.0 %,95.7 %) on the pre- and post-assessments, respectively, with bleeding control scores increasing most (+69.4 %). LFR course trainees scored a median of 34.8 % (IQR: 26.0 %, 43.5 %) and 73.9 % (IQR: 65.2 %, 82.6 %) on the pre- and post-assessments respectively, with airway and breathing increasing the most (+48.6 %). All score increases were statistically significant with p < 0.001. All 30 TOT trainers instructed at least one training session after their initial session. LFR participants' rated confidence in first aid skills went from 3/5 (IQR 3, 4) pre-course to 5/5 (IQR:5,5) post-course, and in emergency transportation it went from 4/5 (IQR:3, 4) to 5/5 (IQR:5, 5), (p < 0.001). LFR course participants rated the quality of education content and TOT instructors to be 5/5 (IQR:5,5). 144 responders provided emergency care in the six-months following training for a total of 351 interventions. Active responders provided a median of 2 (IQR:1,3) interventions. CONCLUSIONS: This is the first time that a digital hybrid instruction for first responder trainers in low- and middle-income countries has been investigated. Our findings demonstrate negligible attrition, high educational quality ratings, equally effective knowledge acquisition to that of prior in-person courses, and high post-training skill usage. Future work will examine the cost-effectiveness of the training of LFRs and the effect of LFRs on trauma outcomes.

Ten years of the community-based emergency first aid responder (EFAR) system in the Western Cape of South Africa: What has happened, what has changed, and what has been learned.

The emergency first aid responder (EFAR) system was designed as a low-cost and adaptable community-based prehospital emergency care system, and was first published after conducting a study in the township of Manenberg, South Africa, in 2010. EFARs are laypersons who are trained to respond to emergencies in their communities, and can provide support to the emergency medical services (EMS) by providing early clinical care, reporting back about the scene, and assisting with local scene management and logistics. Over the past ten years in South Africa, the Western Cape Government Health (WCGH) EMS and the Western Cape Government (WCG) College of Emergency Care have implemented the EFAR system in multiple communities and have trained over 10,000 community members across the Western Cape. This report is a ten-year update on what has happened since the EFAR system started, and to candidly show how the system has evolved, what has been learned, and what challenges remain so that others could look ahead and plan accordingly as they develop similar community-based first aid responder systems in resource-constrained areas. Core pillars to the EFAR system's success have included community involvement and adaptation, collaboration with the WCGH EMS and WCG College of Emergency Care, opportunities for community and EMS development, and emphasis on the sustainability of local EFAR systems. Multiple challenges also remain that others may likely face.

Patterns and outcomes of paediatric trauma at a tertiary teaching hospital in Kenya.

INTRODUCTION: Trauma continues to be a major cause of morbidity and mortality especially in the paediatric population of low- and middle-income countries such as Kenya. The aim of this study was to establish the profile and outcomes of admitted paediatric trauma cases at the Aga Khan University Hospital, Nairobi. METHODS: This retrospective, descriptive study involved a 12-month chart review (January 2016-December 2016). A total of 218 records were identified of which 144 were reviewed. RESULTS: Most injuries were amongst boys (65.3%) and the very young (mean age 6), occurred in private residences (42.4% homes, 25.7% residential institutions), were typically caused by falls (56.3%) or penetrating trauma (13.2%), mostly resulted in extremity fractures (45.8% closed, 4.9% open) and burn or head injuries (in infants and small children), and got very little or no pre-hospital care (51.4% no care). Additionally, children with burns, brain injuries, or poly-trauma had the longest hospital stays and highest rates of mortality. A more detailed description of the patterns and outcomes seen are included in the study. DISCUSSION: Paediatric injuries remain a major public health problem and contribute a substantial proportion of all paediatric surgical admissions at the Aga Khan University Hospital in Nairobi. Based on the patterns and outcomes seen in this study, we therefore recommend for Nairobi (and possibly Kenya) to establish greater supervision and safety measures for children; targeting safety interventions at all children but particularly at boys, the very young, at home and in residential buildings; building pre-hospital emergency care that can accommodate children; and equipping paediatric trauma hospitals to especially handle bony fractures, burns, head injuries, and poly-traumas. A bespoke trauma registry would benefit the hospital, and likely the country as a whole.

Electronic Medical Records in low to middle income countries: The case of Khayelitsha Hospital, South Africa.

INTRODUCTION: Electronic Medical Records (EMRs) have shown benefit for clinical, organisational, and societal outcomes. In low-to-middle-income countries, the desire for EMRs will continue to rise as increasing trauma and infectious disease rates necessitate adequate record keeping for effective follow-up. 114 nations are currently working on national EMRs, with some using both a full EMR (Clinicom) and a paper-based system scanned to an online Enterprise Content Management (ECM) database. METHODS: The authors sought to evaluate the ability and completeness of the EMR at Khayelitsha Hospital (KH) to capture all Emergency Centre (EC) encounters classified as trauma. Based on the high trauma rates in the Khayelitsha area and equally high referral rates from KH to higher-level trauma centres, an assumption was made that its rates would mirror nationwide estimates of 40% of EC visits. Records from July 2012 to June 2013 were examined. RESULTS: 3488 patients visited the EC in the month of July 2012. 10% were noted as trauma on Clinicom and within their records were multiple sections with missing information. The remaining months of Aug 2012-June 2013 had an average trauma load of 8%. On further investigation, stacks of un-scanned patient folders were identified in the records department, contributing to the unavailability of records from January 2013 to the time of study (June 2013) on ECM. CONCLUSION: The results highlight difficulties with implementing a dual record system, as neither the full EMR nor ECM was able to accurately capture the estimated trauma load. Hospitals looking to employ such a system should ensure that sufficient funds are in place for adequate support, from supervision and training of staff to investment in infrastructure for efficient transfer of information. In the long run, efforts should be made to convert to a complete EMR to avoid the many pitfalls associated with handling paper records.

INTRODUCTION: Les dossiers médicaux informatisés (DMI) ont prouvé leur intérêt en termes de résultats cliniques, organisationnels et sociétaux pour de nombreux hôpitaux. Dans les pays à faible et moyen revenu, la volonté de disposer de DMI continuera à progresser à mesure que les taux croissants de traumatismes et de maladies infectieuses exigent une tenue de dossiers adéquate afin d'assurer un suivi efficace. Cent quatorze pays travaillent actuellement à la mise en place de DMI nationaux, certains utilisant à la fois un système de DMI complet (Clinicom) ainsi qu'un système de documents au format papier scannés et ajoutés à une base de données de Gestion de contenu d'entreprise (GCE) en ligne. MÉTHODES: Les auteurs ont cherché à évaluer la capacité et l'exhaustivité du système de DMI au sein de l'hôpital de Khayelitsha (HK) à saisir toutes les visites classées comme traumatismes. Sur la base des forts taux de traumatisme enregistrés dans la région de Khayelitsha, et des taux de renvoi proportionnellement élevés du HK vers des centres de traitement des traumatismes de plus haut niveau, l'hypothèse a été émise que les taux enregistrés dans cet hôpital reflèteraient les estimations nationales de 40 % des visites au CU. Les archives de juillet 2012 à juin 2013 ont été examinées. RÉSULTATS: 3488 patients ont consulté au CU au mois de juillet 2012. Dix pour cent ont été enregistrés comme traumatismes dans Clinicom, plusieurs sections de leur dossier comportant des informations manquantes. Les mois suivants d'août 2012 à juin 2013 indiquaient une proportion de traumatismes de 8 %. Après examen plus approfondi, des piles de dossiers de patients non scannés ont été identifiées au sein du service des dossiers, ceci contribuant à l'indisponibilité des dossiers de janvier 2013 jusqu'au moment de l'étude (juin 2013) dans le GCE. CONCLUSION: Les résultats soulignent les difficultés associées à la mise en œuvre d'un système de tenue de dossiers double, car ni le DMI complet, ni le GCE ne pouvaient saisir avec précision la proportion estimée de traumatisme. Les hôpitaux qui cherchent à utiliser de tels systèmes devraient s'assurer que des fonds suffisants sont disponibles afin de permettre de soutenir adéquatement ce système, allant de la supervision et de la formation du personnel à l'investissement dans les infrastructures, afin de permettre un transfert d'informations efficace. À long terme, des efforts devraient être réalisés afin de pouvoir passer à un système de DMI et d'éviter les nombreux écueils associés à la tenue de dossiers au format papier.

A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa.

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed-ones that can both function in an under-developed area's particular context and be done with the area's limited resources. In this study, we used a two-location pilot and consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, and is designed to not rely on the whole system being implemented first to provide partial function. The University of Cape Town's Division of Emergency Medicine and the Western Cape's provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.

Learning and retention of emergency first aid skills in a violent, developing South African township.

Community members in developing areas can effectively learn first responder training, and skill decay afterwards is not continuous. It is critical that training be done in the trainees' primary language, even if they speak other languages fluently. Making first responder training obligatory for employees and students may be an effective way to generate first responders.

The emergency first aid responder system model: using community members to assist life-threatening emergencies in violent, developing areas of need.

BACKGROUND: As many as 90% of all trauma-related deaths occur in developing nations, and this is expected to get worse with modernisation. The current method of creating an emergency care system by modelling after that of a Western nation is too resource-heavy for most developing countries to handle. A cheaper, more community-based model is needed to establish new emergency care systems and to support them to full maturity. METHODS: A needs assessment was undertaken in Manenberg, a township in Cape Town with high violence and injury rates. Community leaders and successfully established local services were consulted for the design of a first responder care delivery model. The resultant community-based emergency first aid responder (EFAR) system was implemented, and EFARs were tracked over time to determine skill retention and usage. RESULTS: The EFAR system model and training curriculum. Basic EFARs are spread throughout the community with the option of becoming stationed advanced EFARs. All EFARs are overseen by a local organisation and a professional body, and are integrated with the local ambulance response if one exists. On competency examinations, all EFARs tested averaged 28.2% before training, 77.8% after training, 71.3% 4 months after training and 71.0% 6 months after training. EFARs reported using virtually every skill taught them, and further review showed that they had done so adequately. CONCLUSION: The EFAR system is a low-cost, versatile model that can be used in a developing region both to lay the foundation for an emergency care system or support a new one to maturity.

The need for a usable assessment tool to analyse the efficacy of emergency care systems in developing countries: proposal to use the TEWS methodology.

BACKGROUND: Ninety percent of emergency incidents occur in developing countries, and this is only expected to get worse as these nations develop. As a result, governments in developing countries are establishing emergency care systems. However, there is currently no widely-usable, objective method to monitor or research the rapid growth of emergency care in the developing world. METHODS: Analysis of current quantitative methods to assess emergency care in developing countries, and the proposal of a more appropriate method. RESULTS: Currently accepted methods to quantitatively assess the efficacy of emergency care systems cannot be performed in most developing countries due to weak record-keeping infrastructure and the inappropriateness of applying Western derived coefficients to developing country conditions. As a result, although emergency care in the developing world is rapidly growing, researchers and clinicians are unable to objectively measure its progress or determine which policies work best in their respective countries. We propose the TEWS methodology, a simple analytical tool that can be handled by low-resource, developing countries. CONCLUSIONS: By relying on the most basic universal parameters, simplest calculations and straightforward protocol, the TEWS methodology allows for widespread analysis of emergency care in the developing world. This could become essential in the establishment and growth of new emergency care systems worldwide.