Background . Traditional uvulectomy is performed as a cultural ritual or purported medical remedy. We describe the associated emergency department (ED) presentations and outcomes. Methods. This was a subgroup analysis of a retrospective review of all pediatric visits to our ED in 2012. Trained abstracters recorded demographics, clinical presentations, and outcomes. Results . Complete data were available for 5540/5774 (96%) visits and 56 (1.0%, 95% CI: 0.7–1.3%) were related to recent uvulectomy, median age 1.3 years (interquartile range: 7 months–2 years) and 30 (54%) were male. Presenting complaints included cough (82%), fever (46%), and hematemesis (38%). Clinical findings included fever (54%), tachypnea (30%), and tachycardia (25%). 35 patients (63%, 95% CI: 49–75%) received intravenous antibiotics, 11 (20%, 95% CI: 10–32%) required blood transfusion, and 3 (5%, 95% CI: 1–15%) had surgical intervention. All were admitted to the hospital and 12 (21%, 95% CI: 12–34%) died. By comparison, 498 (9.1%, 95% CI: 8–10%) of the 5484 children presenting for reasons unrelated to uvulectomy died (p=0.003). Conclusion . In our cohort, traditional uvulectomy was associated with significant morbidity and mortality. Emergency care providers should advocate for legal and public health interventions to eliminate this dangerous practice.
Neonatal sepsis is a major cause of neonatal mortality. In populations with limited access to health care, early identification of bacterial infections and initiation of antibiotics by community health workers (CHWs) could be lifesaving. It is unknown whether this strategy would be feasible using traditional birth attendants (TBAs), a cadre of CHWs who typically have limited training and educational backgrounds.
Methods:
We analyzed data from the intervention arm of a cluster-randomized trial involving TBAs in Lufwanyama District, Zambia, from June 2006 to November 2008. TBAs followed neonates for signs of potential infection through 28 days of life. If any of 16 criteria were met, TBAs administered oral amoxicillin and facilitated referral to a rural health center.
Results:
Our analysis included 1,889 neonates with final vital status by day 28. TBAs conducted a median of 2 (interquartile range 2–6) home visits (51.4% in week 1 and 48.2% in weeks 2–4) and referred 208 neonates (11%) for suspected sepsis. Of referred neonates, 176/208 (84.6%) completed their referral. Among neonates given amoxicillin, 171/183 (93.4%) were referred; among referred neonates, 171/208 (82.2%) received amoxicillin. Referral and/or initiation of antibiotics were strongly associated with neonatal death (for referral, relative risk [RR] = 7.93, 95% confidence interval [CI] = 4.4–14.3; for amoxicillin administration, RR = 4.7, 95% CI = 2.4–8.7). Neonates clinically judged to be “extremely sick” by the referring TBA were at greatest risk of death (RR = 8.61, 95% CI = 4.0–18.5).
Conclusion:
The strategy of administering a first dose of antibiotics and referring based solely on the clinical evaluation of a TBA is feasible and could be effective in reducing neonatal mortality in remote rural settings.
Even though sub-Saharan Africa faces a disproportionate burden of acute injury and illness, few clinical facilities are configured to take an integrated approach to resuscitation and stabilization. Emergency care is a high-impact and cost-effective form of secondary prevention; disease surveillance at facilities delivering acute and emergency care is essential to guide primary prevention. Barriers to emergency care implementation in the region include limited documentation of the acute disease burden, a lack of consensus on regionally appropriate metrics to facilitate impact evaluation, and the lack of coordinated advocacy for acute disease prevention and emergency care. Despite these challenges, interest in creating dedicated acute care facilities and emergency training programs is rapidly expanding in Africa. We describe one such initiative at Muhimbili National Hospital in Dar es Salaam, with a focus on the development of the emergency medicine residency program.
We applaud Paul Ouma and colleagues' work (March, 2018),1Ouma PO Maina J Thuranira P et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar which highlights the importance of access to emergency care. The authors conclude that 71% of the population in sub-Saharan Africa lives within 2 h of hospital access. Although we appreciate the mapping efforts and data presented in this paper, we do not agree with Ouma and colleagues' central assumption that hospital proximity equals access to emergency services. In reality, most patients with an emergent condition who can access a hospital are likely to be met with limited, ineffective or non-existent emergency care. Actual access to emergency care is much lower than the authors' estimates. Most hospitals in sub-Saharan Africa are without well organised emergency care provision. Many national assessments in the region using the WHO Emergency Care System Assessment Tool have established that first-level hospitals serving most of the population have little capacity for recognition and management of emergency conditions. This situation results from gaps in service delivery organisation, human resources, essential medications and technology, and legislation and government. In terms of service delivery organisation, many first-level hospitals do not have designated emergency units and standardised processes, including triage, resuscitation pathways, condition-specific clinical guidelines and transfer criteria required to treat emergency conditions.2Reynolds T Sawe H Rubiano A Shin S Wallis L Mock C Strengthening health systems to provide emergency care.in: Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank Group, Washington, DC2017Crossref Google Scholar From the perspective of human resources, only ten countries in sub-Saharan Africa have emergency care specialty training programmes. Most frontline providers treat emergency conditions without the benefit of dedicated emergency care training or certification pathways. Many first-level hospitals do not have basic equipment and medications. An essential emergency care package has recently been published2Reynolds T Sawe H Rubiano A Shin S Wallis L Mock C Strengthening health systems to provide emergency care.in: Disease control priorities: improving health and reducing poverty. 3rd edn. World Bank Group, Washington, DC2017Crossref Google Scholar to address this gap and aid in national planning. Finally, few countries in sub-Saharan Africa have the legislative and enforcement mechanisms needed to ensure that access to emergency care is available to those who need it most, regardless of ability to pay. WHO has tools to facilitate improvements in each of the areas above; we specifically encourage efforts that quantify the capacity for emergency care service provision via standardised tools, such as the African Federation for Emergency Medicine's Emergency Care Assessment Tool3Calvello EJ Tenner AG Broccoli MC et al.Operationalising emergency care systems in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.Emerg Med J. 2016; 33: 573-580Crossref PubMed Scopus (21) Google Scholar or the emergency unit module of the WHO hospital assessment tool.4World Health OrganizationEmergency and trauma care.http://who.int/emergencycareDate accessed: May 30, 2018Google Scholar When combined with the mapping analysis provided by Ouma and colleagues,1Ouma PO Maina J Thuranira P et al.Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis.Lancet Glob Health. 2018; 6: e342-e350Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar these objective measures of facility emergency services would be powerful in establishing a more accurate estimate of sub-Saharan Africa's access to emergency care. We declare no competing interests. Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysisPhysical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries. Innovative targeting of emergency care services is necessary to reduce these inequities. This study provides the first spatial census of public hospital services in Africa. Full-Text PDF Open Access
Abstract Background In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specificed in the WHO injury set. Methods This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. Results During the study period, 2,891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5% and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. Conclusions In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.
Objective To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low-and middle-income countries.Methods Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019.Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low-and middle-income setting.To identify additional primary studies, we hand searched the reference lists of included studies.We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. ResultsOf the 1674 articles we identified, 35 articles met the inclusion criteria.We identified an additional four studies from the reference lists.We excluded many studies for being deemed costing assessments without an effectiveness analysis.Most included studies were single-intervention analyses.Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care.The reporting quality of the studies varied.Conclusion We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low-and middleincome settings.Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions.In particular, packages of multiple interventions and system-level changes represent a priority area for future research.
Poisoning is a major public health concern in sub-Saharan Africa, affecting patients of all age groups. Poisoned patients often present to the emergency department (ED) and prompt evaluation and appropriate management are imperative to ensure optimal outcomes. Unfortunately, little is known about the specific presentations of poisoned patients in East Africa. We describe the clinical and epidemiological features of patients presenting to the Muhimbili National Hospital (MNH) ED with suspected toxicological syndromes.This prospective study enrolled a consecutive sample of ED patients who presented with a suspected toxicological syndrome from March 2013 to June 2013. Trained investigators completed a structured case report form (CRF) for each eligible patient, documenting the suspected poison, demographic information, the clinical presentation, and the ED outcome and disposition. The study data were analyzed and summarized with descriptive statistics.Of 8827 patients, who presented to ED-MNH, 106 (1.2%) met inclusion criteria, and all were enrolled. Among those enrolled, the median age was 28 years (interquartile range [IQR] 16 years), and 81 (76.4%) were male. Overall 55 (52%) were single, and 28 (26.4%) had professional jobs. 60 (56.6%) patients were referred from district hospitals, 86.8% of which were in Dar es Salaam. Only 13 (12.3%) of patients presented to the ED within 2 h of the toxic exposure. The etiology of poisoning included alcohol in 42 (50%), a mixture of different medications in 12 (14.3%), and snakebite in 6 (11.3%). Most exposures were intentional (63 [59.4%]) and were via the oral route (88 [83%]). The most common abnormal physical findings were altered mental status (66 [62.3%]) and tachypnoea (68 [64.2%]). One patient died in the ED and 98 (92.5%) required hospital admission.Most patients presenting to the ED with a toxicological syndrome were adult males with intentional exposures. The most common toxic exposure was alcohol (ethanol) intoxication and the most common abnormal findings were altered mental status and tachypnoea. More than three-quarter of patients presented after 2 h of exposure. Almost all patients were admitted to the hospital.
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