Pre-course online cases for the world health organization’s basic emergency care course in Uganda: A mixed methods analysis

Introduction
The Ministry of Health – Uganda implemented the World Health Organization’s Basic Emergency Care course (BEC1) to improve formal emergency care training and address its high burden of acute illness and injury. The BEC is an open-access, in-person, short course that provides comprehensive basic emergency training in low-resource settings. A free, open-access series of pre-course online cases available as downloadable offline files were developed to improve knowledge acquisition and retention. We evaluated BEC participants’ knowledge and self-efficacy in emergency care provision with and without these cases and their perceptions of the cases.

Methods
Multiple Choice Questions (MCQs2) and Likert-scale surveys assessed 137 providers’ knowledge and self-efficacy in emergency care provision, respectively, and focus group discussions explored 74 providers’ perceptions of the BEC course with cases in Kampala in this prospective, controlled study. Data was collected pre-BEC, post-BEC and six-months post-BEC. We used liability analysis and Cronbach alpha coefficients to establish intercorrelation between categorised Likert-scale items. We used mixed model analysis of variance to interpret Likert-scale and MCQ data and thematic content analysis to explore focus group discussions.

Results
Participants gained and maintained significant increases in MCQ averages (15%) and Likert-scale scores over time (p 0.05). Nurses experienced more significant initial gains and long-term decays in MCQ and self-efficacy than doctors (p = 0.009, p < 0.05). Providers found the cases most useful pre-BEC to preview course content but did not revisit them post-course. Technological difficulties and internet costs limited case usage. Conclusion Basic emergency care courses for low-resource settings can increase frontline providers’ long-term knowledge and self-efficacy in emergency care. Nurses experienced greater initial gains and long-term losses in knowledge than doctors. Online adjuncts may enhance health professional education in low-to-middle income countries.

Estimating c-section coverage: Assessing method performance and characterizing variations in coverage

Background
Cesarean section (c-section) is an essential tool for preventing, stillbirths, maternal, and newborn death. However, data on coverage of medically necessary c-section is limited in low- and middle-income settings.

Methods
We estimated national c-section coverage using household survey data from 98 low- and middle-income countries. To disaggregate elective and medically necessary c-sections, we estimated the proportion of women in each survey wealth quintile who gave birth via c-section assuming a denominator that 12.5% of births necessitate a c-section delivery. We capped stratum coverage at 100%. We estimated national c-section coverage weighting for the proportion of births occurring in each wealth quintile. We examined 1) variation in estimated c-section by wealth quintile, national income classification, and stage in the obstetric transition, 2) how varying definitions impact the classification of countries’ access to c-section, and 3) correlation between c-section and related mortality outcomes.

Results
Both increasing national and household wealth are associated with increasing levels of c-section coverage and c-section rate. C-section coverage was highly inequitable by wealth within a country. Differentials in coverage were most pronounced in countries with c-section rates below 10%; however, some countries showed significant gaps in c-section coverage in poor subpopulations despite high c-section rates nationally. The choice of indicator and threshold altered whether a country was classified as having adequate access to c-section services. C-section coverage estimates showed a stronger relationship with closely related health outcomes than national c-section rates.

Conclusions
Generating estimates of c-section coverage is crucial for gauging gaps in c-section access. Our approach for calculating c-section coverage using stratification by wealth to adjust for potential elective c-sections is supported by the strong correlations between household wealth and subnational c-section rate, and the association between our coverage estimates and health outcomes at a national level. Looking at national c-section rates alone may paint an inaccurate picture of c-section access and mask subnational inequities in coverage. The need to accurately measure access to c-section will continue to increase as growth in LMICs drives inequities in coverage and introduces dual concerns related to c-section overuse in some populations while others lack access to care.

Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon

Introduction
Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants’ perceptions on leadership, medical errors, and the QI process in Cameroon.

Methods
Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation.

Results
A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants’ perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. Conclusions These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.

Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis

Background
The accessibility of blood and blood products remains challenging in many countries because of the complex supply chain of short lifetime products, timely access, and demand fluctuation at the hospital level. In an effort to improve availability and delivery times, Rwanda launched the use of drones to deliver blood products to remote health facilities. We evaluated the effect of this intervention on blood product delivery times and wastage.

Methods
We studied data from 20 health facilities between Jan 1, 2015, and Dec 31, 2019, in Rwanda. First, we did a cross-sectional comparison of data on emergency delivery times from the drone operator collected between March 17, 2017, and Dec 31, 2019, with two sources of estimated driving times (Regional Centre for Blood Transfusion estimates and Google Maps). Second, we used interrupted time series analysis and monthly administrative data to assess changes in blood product expirations after the commencement of drone deliveries.

Findings
Between March 17, 2017, and Dec 31, 2019, 12 733 blood product orders were delivered by drones. 5517 (43%) of 12 733 were emergency orders. The mean drone delivery time was 49·6 min (95% CI 49·1 to 50·2), which was 79 min faster than existing road delivery methods based on estimated driving times (p<0·0001) and 98 min faster based on Google Maps estimates (p<0·0001). The decrease in mean delivery time ranged from 3 min to 211 min depending on the distance to the facility and road quality. We also found a decrease of 7·1 blood unit expirations per month after the start of drone delivery (95% CI −11·8 to −2·4), which translated to a 67% reduction at 12 months.

Interpretation
We found that drone delivery led to faster delivery times and less blood component wastage in health facilities. Future studies should investigate if these improvements are cost-effective, and whether drone delivery might be effective for other pharmaceutical and health supplies that cannot be easily stored at remote facilities.

Funding
Canadian Institutes for Health Research.

An outcome of emergency vascular surgery performed by General Surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

Objective: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality.

Method: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20.

Results: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8+11.5 years (range: 14-63 years). Mean duration of hospital stay was 11+3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003).

Conclusion: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Epidemiological characteristics of injury in Georgia: A one-year retrospective study

Introduction
Injury is a major health problem worldwide and a leading cause of death and disability. Disability caused by traumatic injury is often severe and long-lasting. Injuries place a large burden on societies and individuals in the community, both in cost and lost quality of life. Progress in developing effective injury prevention programs in developing countries is hindered by the lack of basic epidemiological injury data regarding the prevalence of traumatic injuries. The aim of this research was to describe the epidemiological characteristics of injury in all hospitals in Georgia.

Methods
The database of the National Center for Disease Control and Public Health of Georgia for 2018, which includes all hospital admissions, was used to identify injury cases treated in hospitals. Cases were included based on the S and T diagnosis coded of ICD-10.

Results
A total of 25,103 adult patients were admitted for an injury, of whom 14,798 (59%) were males and 10,305 (41%) were females, between the ages of 18 and 108 years old. The highest prevalence was among the age group 25–44 years old (n = 8654; 34%), followed by 45–64 years old (n = 6852; 27%). The main mechanism of injury was falls (n = 13,932; 55%) and exposure to mechanical forces (n = 2701; 11%). Over 1,50% (n = 379) of injuries resulted in death after hospitalization. The median hospital length of stay (LOS) was 2 days. There was a significant association between age, mechanism of injury, type of injury, performed surgical interventions, and longer LOS.

Conclusion
Injuries are prevalent throughout the life course and cause substantial hospitalization time. This research can help focus prevention efforts can focus on the demographic and injury causes that are most prevalent.

A qualitative study of an undergraduate online emergency medicine education program at a teaching Hospital in Kampala, Uganda

Background
Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees’ use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course.

Methods
We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed.

Results
Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide.

Conclusions
Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.

Confidence and knowledge in emergency management among medical students across Colombia: A role for the WHO basic emergency care course

Introduction
Globally, medical students have demonstrated knowledge gaps in emergency care and acute stabilization. In Colombia, new graduates provide care for vulnerable populations. The World Health Organization (WHO) Basic Emergency Care (BEC) course trains frontline providers with limited resources in the management of acute illness and injury. While this course may serve medical students as adjunct to current curriculum, its utility in this learner group has not been investigated. This study performs a baseline assessment of knowledge and confidence in emergency management taught in the BEC amongst medical students in Colombia.

Methods
A validated, cross-sectional survey assessing knowledge and confidence of emergency care congruent with BEC content was electronically administered to graduating medical students across Colombia. Knowledge was evaluated via 15 multiple choice questions and confidence via 13 questions using 100 mm visual analog scales. Mean knowledge and confidence scores were compared across demographics, geography and prior training using Chi-Squared or one-way ANOVA analyses.

Results
Data were gathered from 468 graduating medical students at 36 institutions. The mean knowledge score was 59.9% ± 23% (95% CI 57.8–62.0%); the mean confidence score was 59.6 mm ±16.7 mm (95% CI 58.1–61.2). Increasing knowledge and confidence scores were associated with prior completion of emergency management training courses (p<0.0001).

Conclusion
Knowledge and confidence levels of emergency care management for graduating medical students across Colombia demonstrated room for additional, specialized training. Higher scores were seen in groups that had completed emergency care courses. Implementation of the BEC as an adjunct to current curriculum may serve a valuable addition.

Emergency capacity analysis in Ethiopia: Results of a baseline emergency facility assessment

Introduction
In Ethiopia, the specialty of Emergency Medicine is a relatively new discipline. In the last few decades, policymakers have made Emergency Medicine a priority for improving population health. This study aims to contribute to this strengthening of Emergency Medicine, by conducting the country’s first baseline gap analysis of Emergency Medicine Capacity at the pre-hospital and hospital level in order to help identify needs and areas for intervention.

Methods
This is a cross sectional investigation that utilized a convenience sampling of 22 primary, general and tertiary hospitals. Trained personnel visited the hospitals and conducted 4-hour interviews with hospital administrators and emergency care area personnel. The tool used in the interview was the Columbia University sidHARTe Program Emergency Services Resource Assessment Tool (ESRAT) to evaluate both emergency and trauma capacity in different regions of Ethiopia. The findings of this survey were then compared against two established standards: the World Health Organization’s Essential Package of Emergency Care (EPEC), as well as those set by Ethiopia’s Federal Ministry of Health.

Results
The tool assessed the services provided at each hospital and evaluated the infrastructure of emergency care at the facility. Triage systems differed amongst the hospitals surveyed though triaging and emergency unit infrastructures were relatively similar amongst the hospitals. There was a marked variability in the level of training, guidelines, staffing, disaster preparedness, drug availability, procedures performed, and quality assurance measures from hospital to hospital. Most regional and district hospitals did not have nurses or doctors trained in Emergency Medicine and over 70% of the hospitals did not have written guidelines for standardized emergency care.

Conclusion
This gap analysis has revealed numerous inconsistencies in health care practice, resources, and infrastructure within the scope of Emergency Medicine in Ethiopia. Major gaps were identified, and the results of this assessment were used to devise action priorities for the Ministry of Health. Much remains to be done to strengthen Emergency Medicine in Ethiopia, and numerous opportunities exist to make additional short and long-term improvements

The acceptability of delayed consent for prehospital emergency care research in the Western Cape province of South Africa

Background
Informed consent is an essential prerequisite for enrolling patients into a study. Obtaining informed consent in an emergency is complex and often impossible. Delayed consent has been suggested for emergency care research. This study aims to determine the acceptability of prehospital emergency care research with delayed consent in the Western Cape community of South Africa.

Methods
This study was an online survey of a stratified, representative sample of community members in the Western Cape province of South Africa. We calculated a powered sample size to be 385, and a stratified sampling method was employed. The survey was based on similar studies and piloted. Data were analysed descriptively.

Results
A total of 807 surveys were returned. Most respondents felt that enrolment into prehospital research would be acceptable if it offered direct benefit to them (n = 455; 68%) or if their condition was life-threatening and the research would identify improved treatment for future patients with a similar condition (n = 474; 70%). Similar results were appreciable when asked about the participation of their family member (n = 445; 66%) or their child (n = 422; 62%) regarding direct prospects of benefit. Overwhelmingly, respondents indicated that they would prefer to be informed of their own (n = 590; 85%), their family member’s (n = 593; 84%) or their child’s (n = 587; 86%) participation in a study immediately or as soon as possible. Only 35% (n = 283) agreed to retention data of deceased patients without the next of kin’s consent.

Conclusion
We report majority agreement of respondents for emergency care research with delayed consent if the interventions offered direct benefit to the research participant, if the participant’s condition was life-threatening and the work held the prospect of benefit for future patients, and if the protocol for delayed consent was approved by a human research ethics committee. These results should be explored using qualitative methods.