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Fulltext Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

Lecky FE, Reynolds T, Otesile O, Hollis S, Turner J, Fuller G, et al.

BMC Emerg Med, 2020 08 31;20(1):68.
PMID: 32867675 DOI: 10.1186/s12873-020-00362-7

BACKGROUND: More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions.
METHODS: The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.
RESULTS: The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs.
CONCLUSIONS: Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

Matched MeSH terms: Emergency Medical Services/standards*
The evidence for emergency obstetric care

Paxton A, Maine D, Freedman L, Fry D, Lobis S

Int J Gynaecol Obstet, 2005 Feb;88(2):181-93.
PMID: 15694106

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

Matched MeSH terms: Emergency Medical Services/standards*
Improving diagnostic efficiency: analysis of pelvic MRI versus emergency hip aspiration for suspected hip sepsis

Gottschalk HP, Moor MA, Muhamad AR, Wenger DR, Yaszay B

J Pediatr Orthop, 2014 Apr-May;34(3):300-6.
PMID: 24172674 DOI: 10.1097/BPO.0000000000000097

Accurately diagnosing and treating childhood hip sepsis is challenging. Adjacent bone and soft-tissue infections are common and can lead to delayed and inappropriate treatment. This study evaluated the effect of early advanced imaging (bone scan, magnetic resonance imaging) in the management of suspected hip sepsis.

Matched MeSH terms: Emergency Medical Services/standards*
Prehospital emergency medical services in Malaysia

Hisamuddin NA, Hamzah MS, Holliman CJ

J Emerg Med, 2007 May;32(4):415-21.
PMID: 17499697

Once a very slowly developing country in a Southeast Asia region, Malaysia has undergone considerable change over the last 20 years after the government changed its focus from agriculture to developing more industry and technology. The well-known "Vision 2020," introduced by the late Prime Minister, set a target for the nation to be a developed country in the Asia region by the year 2020. As the economy and standard of living have improved, the demand from the public for a better health care system, in particular, emergency medical services (EMS), has increased. Despite the effort by the government to improve the health care system in Malaysia, EMS within the country are currently limited, best described as being in the "developing" phase. The Ministry of Health, Ministry of Education, Civil Defense, and non-governmental organizations such as Red Crescent and St. John's Ambulance, provide the current ambulance services. At the present time, there are no uniform medical control or treatment protocols, communication systems, system management, training or education, or quality assurance policies. However, the recent development of and interest in an Emergency Medicine training program has gradually led to improved EMS and prehospital care.

Matched MeSH terms: Emergency Medical Services/standards
Fulltext Failure to improve door-to-needle time by switching to emergency physician-initiated thrombolysis for ST elevation myocardial infarction

Loch A, Lwin T, Zakaria IM, Abidin IZ, Wan Ahmad WA, Hautmann O

Postgrad Med J, 2013 Jun;89(1052):335-9.
PMID: 23524989 DOI: 10.1136/postgradmedj-2012-131174

INTRODUCTION: Achieving target door-needle times for ST elevation myocardial infarction remains challenging. Data on emergency department (ED) doctor-led thrombolysis in developing countries and factors causing delay are limited.
OBJECTIVES: To assess the effect on door-needle times by transferring responsibility for thrombolysis to the ED doctors and to identify predictors of prolonged door-needle times.
METHODOLOGY: Data on medical on-call team-led thrombolysis at a tertiary Asian hospital were prospectively collected from May 2007 to Aug 2008 (1st study period). In September 2008, ED doctors were empowered to perform thrombolysis. The practice change was accompanied by new guidelines, tick chart implementation, and training sessions. Data were then consecutively collected from September 2008 to May 2009 (2nd study period). Door-to-needle times for the 1st and 2nd study periods were compared. All cases were analysed for factors of delay by multiple logistic regression.
RESULTS: 297 patients were thrombolysed, 169 by the medical on-call team during the 1st study period and 128 by the ED doctors during the 2nd study period. Median door-needle times were 54 and 48 min, respectively (p=0.76). Significant delays were predicted by 'incorrect initial ECG interpretation' (adjusted OR (aOR) 14.3), 'inappropriate triage' (aOR 10.4) and 'multiple referrals' (aOR 5.9). No cases of inappropriate thrombolysis were recorded.
CONCLUSIONS: Transfer of responsibility for thrombolysis to the ED doctors did not improve door-needle times despite measures introduced to facilitate this change. Key causative factors for this failure were identified.
KEYWORDS: Accident & Emergency Medicine; Quality improvement
Study site: Emergency department, University Malaya Medical Centre, Kuala Lumpur

Matched MeSH terms: Emergency Medical Services/standards*
Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia

Shah Jahan MY, Shamila MA, Nurul Azlean N, Mohd Amin M, Anandakumar K, Ahmad Ibrahim KB, et al.

Med J Malaysia, 2019 08;74(4):300-306.
PMID: 31424037

INTRODUCTION: Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured.
CONCLUSION: The guideline highlights select pre-hospital criteria's and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Matched MeSH terms: Emergency Medical Services/standards
Association of the Emergency Medical Services-Related Time Interval with Survival Outcomes of Out-of-Hospital Cardiac Arrest Cases in Four Asian Metropolitan Cities Using the Scoop-and-Run Emergency Medical Services Model

Kim TH, Lee K, Shin SD, Ro YS, Tanaka H, Yap S, et al.

J Emerg Med, 2017 Nov;53(5):688-696.e1.
PMID: 29128033 DOI: 10.1016/j.jemermed.2017.08.076

BACKGROUND: Response time interval (RTI) and scene time interval (STI) are key time variables in the out-of-hospital cardiac arrest (OHCA) cases treated and transported via emergency medical services (EMS).
OBJECTIVE: We evaluated distribution and interactive association of RTI and STI with survival outcomes of OHCA in four Asian metropolitan cities.
METHODS: An OHCA cohort from Pan-Asian Resuscitation Outcome Study (PAROS) conducted between January 2009 and December 2011 was analyzed. Adult EMS-treated cardiac arrests with presumed cardiac origin were included. A multivariable logistic regression model with an interaction term was used to evaluate the effect of STI according to different RTI categories on survival outcomes. Risk-adjusted predicted rates of survival outcomes were calculated and compared with observed rate.
RESULTS: A total of 16,974 OHCA cases were analyzed after serial exclusion. Median RTI was 6.0 min (interquartile range [IQR] 5.0-8.0 min) and median STI was 12.0 min (IQR 8.0-16.1). The prolonged STI in the longest RTI group was associated with a lower rate of survival to discharge or of survival 30 days after arrest (adjusted odds ratio [aOR] 0.59; 95% confidence interval [CI] 0.42-0.81), as well as a poorer neurologic outcome (aOR 0.63; 95% CI 0.41-0.97) without an increasing chance of prehospital return of spontaneous circulation (aOR 1.12; 95% CI 0.88-1.45).
CONCLUSIONS: Prolonged STI in OHCA with a delayed response time had a negative association with survival outcomes in four Asian metropolitan cities using the scoop-and-run EMS model. Establishing an optimal STI based on the response time could be considered.

Matched MeSH terms: Emergency Medical Services/standards*