Emergency Medicine in Guyana: Lessons from Developing the Country's First Degree-conferring Residency Program.

INTRODUCTION: Academic departments of emergency medicine are becoming increasingly involved in assisting with the development of long-term emergency medicine training programs in low and middle-income countries. This article presents our 10-year experience working with local partners to improve emergency medical care education in Guyana. METHODS: The Vanderbilt Department of Emergency Medicine has collaborated with the Georgetown Public Hospital Corporation on the development of Emergency Medicine skills followed by the implementation of an emergency medicine residency training program. Residency development included a needs assessment, proposed curriculum, internal and external partnerships, University of Guyana and Ministry of Health approval, and funding. RESULTS: In our experience, we have found that our successful program initiation was due in large part to the pre-existing interest of several local partners and followed by long-term involvement within the country. As a newer specialty without significant local expertise, resident educational needs mandated a locally present full time EM trained attending to serve as the program director. Both external and internal funding was required to achieve this goal. Local educational efforts were best supplemented by robust distance learning. The program was developed to conform to local academic standards and to train the residents to the level of consultant physicians. Despite the best preparations, future challenges remain. CONCLUSION: While every program has unique challenges, it is likely many of the issues we have faced are generalizable to other settings and will be useful to other programs considering or currently conducting this type of collaborative project.

Who leaves the emergency department without being seen? A public hospital experience in Georgetown, Guyana.

BACKGROUND: Left without being seen (LWBS) proportions are commonly used as quality control indicators, but little data is available on LWBS proportions in the developing world. This study sought to determine the proportion and characteristics of patients who LWBS from the emergency department (ED) of the main public hospital in Georgetown, Guyana. METHODS: This is a retrospective cross-sectional analysis of an ED quality assurance database. Registration personnel collected demographic information on patients presenting to the ED over a 2-week period in July 2010. Both univariate and multivariate analysis were conducted to determine patient characteristics associated with LWBS. RESULTS: The LWBS proportion was 5.7%. In univariate analysis, patients 18 or older (OR 1.48, 95%CI 1.03-2.12), presenting during the 4PM-12AM shift (OR 2.15, 95%CI 1.53-3.01), with non-urgent triage classification (OR 1.88, 95%CI 1.76-4.66), with non-traumatic chief complaints (OR 1.70, 95%CI 1.14-2.55), or who were not transferred (OR 2.13, 95%CI 1.00-4.55) had significantly higher odds of LWBS. On multivariate analysis, only patients 18 or older (OR 1.54, 95%CI 1.02-2.33), presenting during the 4PM-12AM shift (OR 2.29, 95%CI 1.54-3.40), and with non-traumatic chief complaints (OR 2.39, 95%CI 1.43-4.02) were found to be significantly associated with LWBS. Sex, residence in the capital city, time to triage, transfer status, use of EMS, and triage classification were not statistically associated with LWBS. CONCLUSIONS: LWBS proportions are used as quality control indicators and this study determined the LWBS proportion at a public hospital in a developing country and some of the patient characteristics associated with LWBS. This can be helpful to develop strategies to decrease LWBS proportions and to assess progress over time.

Prevalence of intimate partner violence in patients presenting with traumatic injuries to a Guyanese emergency department.

BACKGROUND: Intimate partner violence (IPV) occurs throughout the world, and has both short- term and long- term negative health effects. Little is know about the prevalence of IPV in patients presenting to Emergency Departments (EDs) in the developing world. This information is needed to help delineate the scope of the problem and shape effective interventions to combat IPV. The purpose of this study was to determine the prevalence of intimate partner violence in adult patients with acute traumatic injuries presenting to an ED in Georgetown, Guyana. METHODS: Retrospective descriptive analysis of a prospectively collected ED quality assurance database. Patients 18 years or older who presented with a traumatic injury and answered the question "Was the injury inflicted by a domestic partner?" were included in the analysis. RESULTS: Overall, 38 of 475 (8%) patients admitted to having injuries inflicted by a domestic partner. Thirty- one (81.6%) patients disclosing IPV were female and 7 (18.4%) were male. The self- reported prevalence of IPV in females presenting with traumatic injuries was 16% compared to 2% for males (RR 6.4; 95% CI 2.9-14.3). IPV was the cause of 31 of the 67 (46.3%) women presenting with assaults. CONCLUSIONS: IPV is thought to be a serious problem in Guyana, and this study confirms a high prevalence (16%) of IPV in women presenting with traumatic injuries to the Georgetown Public Hospital Corporation ED. This is likely a significant underestimate of the true prevalence.

Patient perspectives on opt-out HIV screening in a Guyanese emergency department.

In 2007, the WHO recommended that healthcare providers in areas of a generalised HIV epidemic perform HIV testing on all adults and adolescents presenting for healthcare. Studies regarding patient acceptability of opt-out testing, however, have reported wide variation in acceptance rates. This study examines patient-reported acceptability of such testing at the emergency department (ED) of Georgetown Public Hospital Corporation, the largest public hospital in Guyana. In June 2010, a convenience sample of 343 non-critical adult patients who presented to the ED were interviewed regarding potential acceptance of opt-out HIV testing, with 75.5% (95% CI 70.5-80.0%) stating they would accept testing should it be implemented in the ED. Of 12 patient characteristics, 3 had significant differences in acceptance rates on multivariate analysis: age; gender; and previous HIV testing. In this study, potential reasons for declining testing were also examined. The highest percentage of patient agreement was with the statements 'I have had an HIV test recently enough' (84%, 95% CI 74.0-91.4%) and 'I am not at risk for HIV/AIDS' (83%, 95% CI 73.0-90.4%). The results of this study indicate that the majority of patients in this setting would accept opt-out HIV testing, although some still had concerns regarding testing. Opt-out testing in the ED has the potential to facilitate national goals for increased testing and diagnosis.