A feasibility assessment of a traumatic brain injury predictive modelling tool at Kilimanjaro Christian Medical Center and Duke University Hospital.

Traumatic brain injury (TBI) is the most common cause of death and disability globally. TBI, which disproportionately affects low middle-income countries (LMIC), uses significant amounts of health system resources in costly care and management. Innovative solutions are required to address this high burden of TBI. One possible solution is prognostic models which enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a TBI prognostic model developed in Tanzania for use by Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke-affiliated healthcare providers using human centered design methodology. Duke participants were included to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows, co-design interviews were conducted with emergency physicians and nursing staff at KCMC and Duke. Qualitatively, the TBI tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Our knowledge translation method was guided using the knowledge-to-action framework. Of the 21 participants interviewed, 12 were associated with Duke Hospital, and 9 from Kilimanjaro Christian Medical Centre. Emerging from the data were 6 themes that impacted the implementation of the TBI tool: access, barriers, facilitators, use of the TBI tool, outer setting, and inner setting. To our knowledge, this is the first study to investigate the pre-implementation of a sub-Saharan Africa (SSA) data- based TBI prediction tool using human centered design methodology. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC.

International partnerships to foster growth in emergency medicine in Romania.

Emergency medicine (EM) is a growing specialty internationally, but has yet to be cultivated in countries with otherwise advanced health care systems. To promote the growth of EM, emergency physicians from countries where EM is a mature specialty can assist with knowledge transfer and development of emergency medical systems to make a lasting impact on the community served. We present our experience in assisting the development of emergency medicine in a university-affiliated regional hospital in Romania. The International Emergency Medicine Fellowship program at the University of Toronto established links in Cluj-Napoca, Romania, in order to provide expertise and assist local leadership to stimulate growth in EM. In October 2005, a 3-member team travelled to Cluj-Napoca to provide input on how to best use a new physical plant, to deliver continuing education to physicians and nurses, and to help establish long-term development goals. The team identified the following priorities through a comprehensive needs assessment: physical plant organization and patient flow, staffing, staff education, equipment, medication and supplies, and infection control practices. In conjunction with local counterparts, a plan was developed addressing each priority. Staff, hospital administration and university officials report positive growth in EM as a result of the collaboration. Further work is underway to implement the plan, including international exchange trips to promote mutual growth between partners.

West Nile virus. Primer for family physicians.

OBJECTIVE: To provide primary care physicians with an understanding of West Nile virus in North America. This article focuses on epidemiology, clinical features, diagnosis, and prevention of infection. QUALITY OF EVIDENCE: MEDLINE and EMBASE searches revealed epidemiologic, surveillance, cohort, and outcome studies providing level II evidence. There were no randomized controlled trials of treatment. Recommended prevention and treatment strategies are based on level II and III evidence. MAIN MESSAGE: The mosquito-borne virus that first appeared on this continent in 1999 is now prevalent throughout North America. Most infections are asymptomatic. Fewer than 1% of those infected develop severe illness; 3% to 15% of those with severe illness die. While methods for controlling the mosquito population are available, we lack evidence that they reduce infection in the general human population. Family physicians have an important role in advising their patients on ways to prevent infection and in identifying patients who might be infected with West Nile virus. CONCLUSION: The general population is at low risk of West Nile virus infection. Prevention of infection rests on controlling the mosquito population and educating people on how to protect themselves against mosquito bites.

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital.

OBJECTIVES: Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital. METHODS: This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information. RESULTS: Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent. CONCLUSIONS: Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

Needs assessment and staff education to effect long-term change in emergency medicine in rural Nepal.

Medical work in developing countries is challenging and rewarding. To make a lasting impact on the local community, a health care worker must be willing to listen to the needs of the people. The long-term impact of a needs assessment and staff education on emergency medicine at a rural hospital in Nepal is presented. The Scheer Memorial Hospital is a 102-bed non-governmental, not-for-profit hospital in Banepa, Nepal. Nepalese and ex-patriot health care professionals staff the hospital. Medical supplies are obtained from local manufacturers or as donations from foreign organizations. The hospital waives fees for those who cannot afford care. Two academic emergency physicians with expertise in international health undertook a needs assessment to assist in planning for long-term health care goals related to emergency medicine. The assessment focused on health care planning and education of the local health care staff. Based on interviews and objective assessments, a plan was developed and implemented to address 4 key areas: physical plant, equipment, staff training and essential tasks. Sustainable positive change was accomplished by acknowledging local customs and standards of care, meeting the needs of local health care staff and using available resources.