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BackgroundSevere acute respiratory infections (SARIs) are the leading cause of pediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care of patients are critical to improving patient outcomes. The aim of this systematic review was to evaluate the impact of emergency care interventions on improving clinical outcomes of pediatric patients with SARIs in LMICs.MethodsPubMed, Global Health, and Global Index Medicus electronic databases were searched to identify peer-reviewed clinical trials or studies with comparator groups published before November 2020. All studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs were included. Given the heterogeneity of interventions and outcomes, a narrative synthesis was performed. Bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions.Results20,583 studies were screened, with 99 meeting criteria for final inclusion. The most common conditions studied were pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). The majority of studies evaluated medications (80.8%), followed by respiratory support (14.1%) and supportive care (5%). The strongest evidence of benefit was found for respiratory support interventions such as improved medical oxygen systems to decrease risk of death. Results were notably inconclusive on the utility of continuus positive airway pressure (CPAP). Mixed results were found for interventions for bronchiolitis, although possible benefit was found for hypertonic nebulized saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes.ConclusionsWhile the burden of SARI in pediatric populations is high, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for decreasing hospital length of stay and mortality and improvement of clinical status. Further research on the use of CPAP in diverse settings and populations is needed. A stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions, is greatly needed.

Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients10 years old with SARIs in LMICs.A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools.20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity.We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed.PROSPERO registration number: CRD42020216117.

Introduction Acute childhood illnesses, such as malaria, pneumonia, and diarrhoea, represent the leading causes of under-five mortality in Uganda. Given that most early child deaths are treatable with timely interventions, emergency units dedicated to paediatric populations have been established in the country. In light of recent developments, the department of paediatrics at Makerere University requested a needs assessment in the paediatric acute care unit (PACU) at Mulago National Referral Hospital, which could guide the development of a new training curriculum for medical providers. Methods We administered a survey for medical providers working in the PACU at Mulago Hospital, which assessed their self-rated comfort levels with paediatric assessment, treatment, and teamwork skills. We also conducted focus groups with a smaller subset of medical providers to understand barriers and facilitators to paediatric emergency and critical care. Results Of 35 paediatric assessment, treatment, and teamwork skills, 29 (83%) questions had the median comfort rating of 6 or 7 on a 7-point Likert scale. The remaining 6 (17%) skills had a median comfort rating of 5 or lower. Focus groups identified a number of major barriers to caring for critically ill children, including limited resources and staffing, training gaps, and challenges with interprofessional teamwork. In terms of training development, focus group participants suggested continuous training for all medical providers working in the PACU led by local leaders. Discussion This study identified the need and desirability of continuous trainings in the PACU. Key components include objective skills assessment, simulation-based scenarios, and interprofessional teamwork. Training development should be augmented by increases in resources, staffing, and training opportunities in collaboration with the Uganda Ministry of Health.

ObjectivesEmergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This study sought to increase knowledge of quality through identifying all publications from Africa containing data relevant to the AFEM-CC process clinical and outcome quality indicators.DesignWe conducted searches for general quality of emergency care in Africa and for each of 28 AFEM-CC process clinical and five outcome clinical quality indicators individually in the medical and grey literature.Data sourcesPubMed (1964—2 January 2022), Embase (1947—2 January 2022) and CINAHL (1982—3 January 2022) and various forms of grey literature were queried.Eligibility criteriaStudies published in English, addressing the African emergency care population as a whole or large subsegment of this population (eg, trauma, paediatrics), and matching AFEM-CC process quality indicator parameters exactly were included. Studies with similar, but not exact match, data were collected separately as ‘AFEM-CC quality indicators near match’.Data extraction and synthesisDocument screening was done in duplicate by two authors, using Covidence, and conflicts were adjudicated by a third. Simple descriptive statistics were calculated.ResultsOne thousand three hundred and fourteen documents were reviewed, 314 in full text. 41 studies met a priori criteria and were included, yielding 59 unique quality indicator data points. Documentation and assessment quality indicators accounted for 64% of data points identified, clinical care for 25% and outcomes for 10%. An additional 53 ‘AFEM-CC quality indicators near match’ publications were identified (38 new publications and 15 previously identified studies that contained additional ‘near match’ data), yielding 87 data points.ConclusionsData relevant to African emergency care facility-based quality indicators are highly limited. Future publications on emergency care in Africa should be aware of, and conform with, AFEM-CC quality indicators to strengthen understanding of quality.

The emergency department (ED) discharge process often involves haste and poor communication.To assess the association of an automated telephone call 2 days after ED discharge with the likelihood of an unplanned ED revisit at both 72 hours and 7 days after the index visit and with perceived care metrics measured at 14 days.This prospective nonrandomized clinical trial was conducted at a single academically affiliated county emergency department among 8110 patients presenting to and discharged from the ED during a 10-week period from June 25 to August 30, 2018. Initial statistical analysis was performed from February 1 to November 30, 2020, with additional analyses performed from March 1 to 16, 2022.Participants were allocated in a nonrandom fashion to 1 of 2 groups: patients who received an automated telephone call 2 days after discharge were compared with patients who received no call 2 days after discharge. All patients received a telephone questionnaire at 14 days to assess secondary outcome measures.The primary outcome was a return visit to the ED at 7 days. Secondary outcomes included a return visit to the ED within 72 hours, a return visit to the ED within 7 days resulting in hospital admission, and patient-reported perceptions of their care measured by 4 questions related to quality metrics assessed at 14 days. A secondary analysis compared patients who actually responded to the initial call at 2 days with all nonresponders, regardless of whether they received a call. Analyses were made on an intention-to-treat basis.More than 15 000 patients were seen in the ED during the 10-week study period, and 10 948 were discharged. A total of 8110 patient encounters (4460 male patients [55.0%]; 3313 Hispanic patients [40.9%]; mean [SD] age, 40.5 [19.4] years) were enrolled. A total of 2958 patients (36.5%) received an automated telephone call at 2 days after discharge, while 5152 (63.5%) received no call. Rates of ED return within 7 days of the initial index visit were significantly lower among those who received a call at 2 days than those who did not receive a call (224 of 2958 [7.6%] vs 533 of 5152 [10.3%]; P .001). Patients who received a 2-day call were more likely than those who did not receive a call to have followed up with a health care clinician (67.9% [374 of 551] vs 66.3% [604 of 911]), understood their health issues (77.5% [490 of 632] vs 74.9% [780 of 1042]), and have received their discharge medications (87.0% [507 of 583] vs 83.6% [793 of 949]), although none of these differences between the 2 groups were statistically significant.A telephone call to patients 2 days after discharge from the ED was associated with decreased ED use at 7 days after the index visit and may have been associated with marginal improvements in measured quality of care metrics.

Background Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India. Methods From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide). Lessons learned During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials. Conclusion These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

Objectives:This review systematically explores the current available evidence on the effectiveness of interventions provided to first responders to prevent and/or treat the mental health effects of responding to a disaster.Methods:A systematic review of Medline, Scopus, PsycINFO, and gray literature was conducted. Studies describing the effectiveness of interventions provided to first responders to prevent and/or treat the mental health effects of responding to a disaster were included. Quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and the Critical Appraisal Skills Programme (CASP) checklist.Results:Manuscripts totaling 3869 met the initial search criteria; 25 studies met the criteria for in-depth analysis, including 22 quantitative and 3 qualitative studies; 6 were performed in low- and middle-income countries (LMICs); 18 studies evaluated a psychological intervention; of these, 13 found positive impact, 4 found no impact, and 1 demonstrated worsened symptoms after the intervention. Pre-event trainings decreased psychiatric symptoms in each of the 3 studies evaluating its effectiveness.Conclusions:This review demonstrates that there are likely effective interventions to both prevent and treat psychiatric symptoms in first responders in high-, medium-, and low-income countries.

Background Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population. Methods We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality. Results We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25–50) and were predominately male (72%, N = 2088), of lower economic status (97%, N = 2805 used a government issued ration card) and were from rural or tribal areas (74%, N = 2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4–14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2–7)), on-scene mobility (OR 2.8 (95% CI: 1.3–6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1–5)). Conclusions EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.

ObjectivesThis project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.DesignWe conduct a two-arm, controlled, mixed-methods, hybrid type II study.SettingThis study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.InterventionsWe pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measuresWe assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).ConclusionsIn this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

BackgroundOver 50% of annual deaths in low-income and middle-income countries (LMICs) could be averted through access to high-quality emergency care.ObjectivesWe performed a scoping review of the literature that described at least one measure of emergency care access in LMICs in order to understand relevant barriers to emergency care systems.Eligibility criteriaEnglish language studies published between 1 January 1990 and 30 December 2020, with one or more discrete measure(s) of access to emergency health services in LMICs described.Source of evidencePubMed, Embase, Web of Science, CINAHL and the grey literature.Charting methodsA structured data extraction tool was used to identify and classify the number of ‘unique’ measures, and the number of times each unique measure was studied in the literature (‘total’ measures). Measures of access were categorised by access type, defined by Thomas and Penchansky, with further categorisation according to the ‘Three Delay’ model of seeking, reaching and receiving care, and the WHO’s Emergency Care Systems Framework (ECSF).ResultsA total of 3103 articles were screened. 75 met full study inclusion. Articles were uniformly descriptive (n=75, 100%). 137 discrete measures of access were reported. Unique measures of accommodation (n=42, 30.7%) and availability (n=40, 29.2%) were most common. Measures of seeking, reaching and receiving care were 22 (16.0%), 46 (33.6%) and 69 (50.4%), respectively. According to the ECSF slightly more measures focused on prehospital care—inclusive of care at the scene and through transport to a facility (n=76, 55.4%) as compared with facility-based care (n=57, 41.6%).ConclusionsNumerous measures of emergency care access are described in the literature, but many measures are overaddressed. Development of a core set of access measures with associated minimum standards are necessary to aid in ensuring universal access to high-quality emergency care in all settings.

ObjectivePrevious studies have assessed patient-level characteristics associated with emergency department (ED) return visits, but none have used provider assessment. We prospectively investigate whether clinical providers could accurately predict ED return visits.MethodsProspective cohort study.SettingSingle academically affiliated urban county hospital.ParticipantsDischarged ED patients over a 14-month period with a provider assessment of the likelihood of patient return within 7 days of ED discharge.Main outcome measuresThe primary outcome of interest was a return visit to the ED within 7 days. Additional outcome measures included a return visit within 72 hours and a return visit resulting in admission. We also measured the accuracy of provider gestalt, and provide measures of sensitivity, specificity, predictive values, and likelihood ratios.ResultsOf the 11 922 ED discharges included in this study, providers expected 2116 (17.7%) to result in a return visit within 7 days. Providers were much more likely to perceive a return visit if the patient left against medical advice (OR: 5.97, 95% CI: 4.67 to 7.62), or was homeless (OR: 5.69, 95% CI: 5.14 to 6.29). Patients who actually returned were also more likely to be homeless, English speaking and to have left the ED against medical advice on the initial encounter. The strongest predictor of a return visit at both 72 hours and 7 days in multivariable modelling was provider assessment (OR: 3.77, 95% CI: 3.25 to 4.37; OR: 3.72, 95% CI: 3.29 to 4.21, respectively). Overall sensitivity and specificity of provider gestalt as a measure of patient return within 7 days were 47% and 87%, respectively. The positive and negative likelihood ratios were 3.51 and 0.61, respectively.ConclusionsClinician assessment was the strongest predictor of a return visit in this dataset. Clinician assessment may be used as a way to screen patients during the index visit and enrol them in efforts to decrease return visits.

Background Despite large reductions in under-5 lower respiratory infection (LRI) mortality in many locations, the pace of progress for LRIs has generally lagged behind that of other childhood infectious diseases. To better inform programmes and policies focused on preventing and treating LRIs, we assessed the contributions and patterns of risk factor attribution, intervention coverage, and sociodemographic development in 195 countries and territories by drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) LRI estimates. Methods We used four strategies to model LRI burden: the mortality due to LRIs was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive ensemble modelling tool; the incidence of LRIs was modelled using population representative surveys, health-care utilisation data, and scientific literature in a compartmental meta-regression tool; the attribution of risk factors for LRI mortality was modelled in a counterfactual framework; and trends in LRI mortality were analysed applying changes in exposure to risk factors over time. In GBD, infectious disease mortality, including that due to LRI, is among HIV-negative individuals. We categorised locations based on their burden in 1990 to make comparisons in the changing burden between 1990 and 2017 and evaluate the relative percent change in mortality rate, incidence, and risk factor exposure to explain differences in the health loss associated with LRIs among children younger than 5 years. Findings In 2017, LRIs caused 808 920 deaths (95% uncertainty interval 747 286–873 591) in children younger than 5 years. Since 1990, there has been a substantial decrease in the number of deaths (from 2 337 538 to 808 920 deaths; 65·4% decrease, 61·5–68·5) and in mortality rate (from 362·7 deaths [330·1–392·0] per 100 000 children to 118·9 deaths [109·8–128·3] per 100 000 children; 67·2% decrease, 63·5–70·1). LRI incidence declined globally (32·4% decrease, 27·2–37·5). The percent change in under-5 mortality rate and incidence has varied across locations. Among the risk factors assessed in this study, those responsible for the greatest decrease in under-5 LRI mortality between 1990 and 2017 were increased coverage of vaccination against Haemophilus influenza type b (11·4% decrease, 0·0–24·5), increased pneumococcal vaccine coverage (6·3% decrease, 6·1–6·3), and reductions in household air pollution (8·4%, 6·8–9·2). Interpretation Our findings show that there have been substantial but uneven declines in LRI mortality among countries between 1990 and 2017. Although improvements in indicators of sociodemographic development could explain some of these trends, changes in exposure to modifiable risk factors are related to the rates of decline in LRI mortality. No single intervention would universally accelerate reductions in health loss associated with LRIs in all settings, but emphasising the most dominant risk factors, particularly in countries with high case fatality, can contribute to the reduction of preventable deaths. Funding Bill & Melinda Gates Foundation.

A changing climate will have demonstrable effects on health and healthcare systems, with specific and disproportionate effects on communities in Africa. Emergency care systems and providers have an opportunity to be at the forefront of efforts to combat the worst health effects from climate change. The 2020 African Conference on Emergency Medicine, under the auspices of the African Federation for Emergency Medicine, convened its first ever workshop on the topic of climate change and human health. Structured as a full day virtual course, the didactic sections were available for both live and asynchronous learning with more than 100 participants enrolled in the course. The workshop introduced the topic of the health effects of climate as they relate to emergency care in Africa and provided a forum to discuss ideas regarding the way forward. Lectures and focused discussions addressed three broad themes related to: health impacts, health care delivery, and advocacy. To our knowledge, this is the first workshop for health professionals to cover topics specific to emergency care, climate change, and health in Africa. The results of this workshop will help to guide future efforts aimed at advancing emergency care approaches in Africa with regard to medical education, research, and policy. African relevance • Climate-related extreme weather events are adversely affecting health and health care delivery in African countries. • African organisations, cities, and nations have taken positive steps to adapt and build climate resilience. • There are opportunities for emergency care professionals and scholars to continue to expand, and lead, climate and health education, research, and policy initiatives on the continent.

BackgroundLow/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India.MethodsWe conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables.ResultsWe enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2).DiscussionAlthough EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

Study Objectives: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring suspected COVID-19 patients upon initial presentation to the health care system, and to evaluate the utility of these tools in LRS. A scoping review was conducted to identify studies describing acute screening, triage, and severity scoring of suspected COVID-19 patients published between 12 December, 2019 and 01 April, 2020. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. The initial search strategy yielded 15232 articles;124 met inclusion criteria. Results: Most studies were from China (n=41, 33.1%) or the United States (n=23, 18·5%). In total, 57 screening, 54 severity scoring, and 23 triage tools were described. A total of 23 tools–16 screening, four triage, and three severity scoring–were identified as feasible for use in LRS. A total of 37 studies provided validation data: four prospective and 33 retrospective, with none from low-income and lower-middle-income countries. Conclusions: This study identified a number of screening, triage, and severity scoring tools implemented and proposed for suspected COVID-19 patients. No tools were specifically designed and validated in LRS. A tool specific to resource limited context is crucial to reducing mortality in the current pandemic.

Objectives Severe global shortages in the health care workforce sector have made improving access to essential emergency care challenging. The paucity of trained specialists in low- and middle-income countries translates to large swathes of the population receiving inadequate care. Efforts to expand emergency medicine education are similarly impeded by a lack of available and appropriate teaching faculty. The development of comprehensive, online medical education courses offers a potentially economical, scalable, and lasting solution for universities experiencing professional shortages. Methods An emergency medicine course addressing core concepts and patient management was developed for medical students enrolled at Makerere University College of Health Sciences in Kampala, Uganda. Material was presented to students in two comparable formats: online video modules and traditional classroom-based lectures. Following completion of the course, students were assessed for knowledge gains. Results 42 and 48 students enrolled and completed all testing in the online and classroom courses, respectively. Student knowledge gains were equivalent (classroom 25% ± 8.7 vs online 23% ± 6.5, p=0.18), regardless of the method of course delivery. Conclusions A summative evaluation of Ugandan medical students demonstrated that online teaching modules are effectively equivalent and offer a viable alternative to traditional classroom-based lectures delivered by on-site, visiting faculty in their efficacy to teach expertise in emergency medicine. Web-based curriculum can help alleviate the burden on universities in developing nations struggling with a critical shortage of health care educators while simultaneously satisfying the growing community demand for access to emergency medical care. Future studies assessing the long-term retention of course material could gauge its incorporation into clinical practice. This article is protected by copyright. All rights reserved.

Background: Purposefully designed and validated screening, triage, and severity scoring tools are needed to reduce mortality of COVID-19 in low-resource settings (LRS). This review aimed to identify currently proposed and/or implemented methods of screening, triaging, and severity scoring suspected COVID-19 patients upon initial presentation to the healthcare system, and to evaluate the utility of these tools in LRS. Methods: A scoping review was conducted to identify studies describing screening, triage, and severity scoring of suspected COVID-19 patients published between December 12, 2019 and September 01, 2020. Extracted information included clinical features, use of laboratory and imaging studies, and relevant tool validation data. Findings: The initial search strategy yielded 14,350 articles. A total of 93 manuscripts met inclusion criteria. Most studies were from China (n=37, 39.8%) or the United States (n=15, 16·1%). In total, 51 screening, 39 severity scoring tools, and 20 triage tools were described; 13 of these – nine for screening, two for triage, and two for severity scoring – were identified as feasible in LRS and were being used in such settings. A total of 31 studies provided validation data: four prospective and 27 retrospective, with none from low-income and lower-middle-income countries. Interpretation: This study identified a wide range of screening, triage, and severity scoring tools implemented and proposed for suspected COVID-19 patients. No tools were designed and validated in LRS. A tool specific to resource limited context is crucial to reducing mortality in the current pandemic. Funding: No funding was received for this study. Declaration of Interests: The authors declare no competing interests.

BackgroundIn India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint.MethodsPediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality.ResultsA total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation ConclusionsThis is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.

Background Currently, Myanmar does not have a nationalized emergency care or emergency medical services (EMS) system. The provision of emergency medicine (EM) education to physicians without such training is essential to address this unmet need for high quality emergency care. We queried a group of healthcare providers in Myanmar about their experience, understanding and perceptions regarding the current and future needs for EM training in their country. Methods A 34-question survey was administered to a convenience sample of healthcare workers from two primary metropolitan areas in Myanmar to assess exposure to and understanding of emergency and pre-hospital care in the country. Results 236 of 290 (81% response rate) individuals attending one of two full-day symposia on emergency medicine completed the survey. The majority of respondents were female (n=138, 59%), physicians (n=171, 74%), and working in private practice (n=148, 64%). A majority of respondents (n=133, 57%) spent some to all of their clinical time providing acute and emergency care however 83.5% (n=192) of all surveyed reported little or no past training in emergency care; and those who have received prior emergency medicine training were more likely to care for emergencies (>2 weeks training; p=.052). 81% (n= 184) thought the development of emergency and acute care services should be a public health priority. Conclusions Although this subset of surveyed health practitioners commonly provides acute care, providers in Myanmar may not have adequate training in emergency medicine. Continued efforts to train Myanmar’s existing healthcare workforce in emergency and acute care should be emphasized.

Introduction The purpose of the study was to critically analyse financial management of the public Emergency Medical Services (EMS) sector with specific focus on the financing methods for public EMS. Methods The study is a descriptive cross-sectional quantitative survey. It was conducted in the Department of EMS at the Ministry of Health, Uganda. A census was conducted for all twenty-one members of the Department of EMS. Data was collected with the use of a structured questionnaire. Results The prominent sources of funding towards EMS in Uganda included government, development partners and charity organizations. The most highlighted factors constraining financial management of EMS included reduced government funding, bureaucracies within government agencies and increasing costs of running EMS. The major strategies to improve on the financial constraints included formation of a national insurance scheme, increasing government's contribution and forming Public-Private Partnerships. Conclusion The department seemed to be taking on the trend of the developed world in form of strategies to combat financial management constraints which is a step in the right direction but should be cognizant of the challenges this could bring on due to adaptation of these practices. The department of EMS still had a narrow scope of funding sources mainly circling around government and development partner support and was utilizing less of the more contemporary sources mainly exercised by the developed world., African relevance • There has been a paucity of work regarding the financial management of Emergency Medical Services in Africa. • The right financing mix is pivotal to building capacity into Emergency Medical Services in Africa. • African countries can learn from each other's unique systems.

Background Global health (GH) interest is increasing in graduate medical education (GME). The popularity of the GH topic has created growth in the GME literature. Objective The authors aim to provide a systematic review of published approaches to GH in GME. Methods We searched PubMed using variable keywords to identify articles with abstracts published between January 1975 and January 2015 focusing on GME approaches to GH. Articles meeting inclusion criteria were evaluated for content by authors to ensure relevance. Methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity evidence. Results Overall, 69 articles met initial inclusion criteria. Articles represented research and curricula from a number of specialties and a range of institutions. Many studies reported data from a single institution, lacked randomization and/or evidence of clinical benefit, and had poor reliability and validity evidence. The mean MERSQI score among 42 quantitative articles was 8.87 (2.79). Conclusions There is significant heterogeneity in GH curricula in GME, with no single strategy for teaching GH to graduate medical learners. The quality of literature is marginal, and the body of work overall does not facilitate assessment of educational or clinical benefit of GH experiences. Improved methods of curriculum evaluation and enhanced publication guidelines would have a positive impact on the quality of research in this area.

Objectives To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. Design Prospective observational study. Setting Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014. Participants Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a ‘pregnancy-related’ problem. Initial calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded. Main outcome measures: death at 2, 7 and 42 days after delivery. Results Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21–25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality. Conclusions The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Objectives Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS). Design Prospective observational study. Setting Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. Participants This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a ‘pregnancy-related’ problem for free-of-charge ambulance transport. Calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded. Main outcome measures Emergency medical technician (EMT) interventions, method of delivery and death. Results The median age enrolled was 23 years (IQR 21–25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51–84) vs 56 min (IQR 42–73), respectively, p

A qualitative study of the experiences of rescue and recovery workers/volunteers at Ground Zero following the terrorist attacks of 9/11/01 is reported. Information was extracted from a semi-structured clinical evaluation of 416 responders who were the initial participants in a large scale medical and mental health screening and treatment program for 9/11 responders. Qualitative analysis revealed themes that spanned four categories- occupational roles, exposures, attitudes/experiences, and outcomes related to the experience of Ground Zero. Themes included details regarding Ground Zero roles, grotesque experiences such as smells, the sense of the surreal nature of responding, and a turning to rituals to cope after leaving Ground Zero. These findings personalize the symptom reports and diagnoses that have resulted from the 9/11 responders' exposure to Ground Zero, yielding richer information than would otherwise be available for addressing the psychological dimensions of disasters. This work shows that large scale qualitative surveillance of trauma-exposed populations is both relevant and feasible.

The emergence of global health as a core component of medical education is a relatively recent phenomenon.1 Over the last 20 years, graduate medical education (GME) has documented the growth, curriculum development, and trainee benefits of global health electives (GHEs).2 Scholarship, predominantly focused on evidence-based benefits and clinical outcomes of GHEs at the community level, has not occurred at the same pace. Efforts to standardize and understand benefits of a GHE curriculum should occur in parallel with the need to monitor and evaluate the effects of GHEs on clinical and public health outcomes. Viewed within the framework of a translational science, GHEs have the potential to (re)focus attention on improved clinical health outcomes in low-resource settings. The process of understanding (global) medical education as a translational science involves: rigorous study on clinical skill and knowledge (T1), the translation of said knowledge into the delivery of better health care (T2), and the study of improved patient or public health outcomes (T3).3 Current global health education and scholarship are primarily focused on academic understanding at the T1 and T2 levels but is most lacking at the T3 level. Both high-quality clinical health studies from global health settings4 and studies linking educational activities and health outcomes in the United States5 do exist. There is far less literature linking GHEs and clinical outcomes. The presence of visiting health workers is assumed to yield health benefits to local populations, but little explicit data exist beyond small descriptive studies.6,7

On January 12, 2010, a 7.0-magnitude earthquake struck Haiti. The event disrupted infrastructure and was marked by extreme morbidity and mortality. The global response to the disaster was rapid and immense, comprising multiple actors-including academic health centers (AHCs)-that provided assistance in the field and from home. The authors retrospectively examine the multidisciplinary approach that the University of Chicago Medicine (UCM) applied to postearthquake Haiti, which included the application of institutional structure and strategy, systematic deployment of teams tailored to evolving needs, and the actual response and recovery. The university mobilized significant human and material resources for deployment within 48 hours and sustained the effort for over four months. In partnership with international and local nongovernmental organizations as well as other AHCs, the UCM operated one of the largest and more efficient acute field hospitals in the country. The UCM's efforts in postearthquake Haiti provide insight into the role AHCs can play, including their strengths and limitations, in complex disasters. AHCs can provide necessary intellectual and material resources as well as technical expertise, but the cost and speed required for responding to an emergency, and ongoing domestic responsibilities, may limit the response of a large university and hospital system. The authors describe the strong institutional backing, the detailed predeployment planning and logistical support UCM provided, the engagement of faculty and staff who had previous experience in complex humanitarian emergencies, and the help of volunteers fluent in the local language which, together, made UCM's mission in postearthquake Haiti successful.

Introduction:Western media coverage of the violence associated with the 2003 US-led invasion of Iraq has contrasted in magnitude and nature with population-based survey reports.Objectives:The purpose of this study was to evaluate the extent to which first-hand reports of violent deaths were captured in the English language media by conducting in-depth interviews with Iraqi citizens.Methods:The England-based Iraq Body Count (IBC) has methodically monitored media reports and recorded each violent death in Iraq that could be confirmed by two English language media sources. Using the capturerecapture method, 25 Masters' Degree students were assigned to interview residents in Iraq and asked them to describe 10 violent deaths that occurred closest to their home since the 2003 invasion. Students then matched these reports with those documented in IBC. These reports were matched both individually and crosschecked in groups to obtain a percentage of those deaths captured in the English language media.Results:Eighteen out of 25 students successfully interviewed someone in Iraq. Six contacted individuals by telephone, while the others conducted interviews via e-mail. One out of seven (14%) phone contacts refused to participate. Seventeen out of 18 primary interviewees resided in Baghdad, however, some interviewees reported deaths of neighbors that occurred while the neighbors were elsewhere. The Baghdad residents reported 161 deaths in total, 39 of which (24%) were believed to be reported in the press as summarized by IBC. An additional 13 deaths (8%) might have been in the database, and 61 (38%) were absolutely not in the database.Conclusions:The vast majority of violent deaths (estimated from the results of this study as being between 68–76%) are not reported by the press. Efforts to monitor events by press coverage or reports of tallies similar to those reported in the press, should be evaluated with the suspicion applied to any passive surveillance network: that it may be incomplete. Even in the most heavily reported conflicts, the media may miss the majority of violent events.

Background Disaster workers responding to the events of September 11th were exposed to traumatic events. No study has systematically investigated the diverse mental health status and needs of the heterogeneous population of disaster workers responding to the events of September 11th. Methods Using PubMed and Medline and the search terms of "September 11, 2001" or "September 11" or "9/11"or "WTC" or "World Trade Center", the authors reviewed all articles that examined the mental health outcomes of workers at one of the three September 11th crash sites or the Fresh Kills landfill in New York City. Results In total, 25 articles met study inclusion criteria, often using different methodologies. The articles described varying degrees of mental health symptomatology, risk factors for adverse mental health outcomes, and utilization of mental health services. Conclusions The mental health needs of workers exposed to the events of September 11th ranged from little to no care to pharmacotherapy. A range of risk factors, including exposures at the WTC site and occupational activities, impacted on these needs but the role of specific mental health interventions was less clear. These findings suggest the need for a future program for disaster workers consisting of an accessible mental health treatment service supported by comprehensive postdisaster surveillance and emphasis on pre-disaster mental wellness. A number of areas for further consideration and study were identified, including the need for a more diverse exploration of involved responder populations as well as investigation of potential mental health outcomes beyond post-traumatic stress disorder (PTSD).

Suicide is the 11 th leading cause of death in the United States. The objective of this study is to document the characteristics of aviation-related suicides and suicide attempts.Aviation accidents reported by the National Transportation Safety Board between 1983 and 2003 were screened for cases in which suicide was listed as a probable cause. For each suicide case, two accidents were randomly selected as controls, matched on sex of pilot, type of flight, state, and year of occurrence. Mantel-Haenszel summary Chi-square tests were used to compare cases to controls. Conditional logistic regression modeling was performed to assess the association of pilot and flight characteristics with suicide-related crashes.During the 21-yr study period, 37 pilots committed or attempted suicide by aircraft, with 36 resulting in at least one fatality. All the cases were men and involved general aviation flights. Toxicological test results revealed that 24% of the cases had used alcohol and 14% had used other illicit drugs. Underlying factors included domestic and social problems (46%), legal trouble (40%), and pre-existing psychiatric conditions (38%). Compared with controls, suicide cases involved younger pilots (p0.05), were less likely to have another occupant (p0.0001), were more destructive to the aircraft (p0.0001), and were more likely to have occurred away from the airport (p0.0001).Aviation crashes caused by suicide differ from unintentional aviation accidents in pilot characteristics, crash circumstances, and outcomes.

The relationship between homicide and suicide has been studied extensively, but with conflicting results. The primary objective of this study was to examine the correlation between homicide and suicide rates in a large cross-sectional sample of UN member states.The study used age-standardized data on homicide and suicide for 65 international locales compiled by the World Health Organization. Weighted correlation coefficients between homicide and suicide rates were computed by sex, income level, and geographic region.The overall correlation between homicide and suicide rates was weak and statistically insignificant (rho = -0.08, P = 0.5178). However, when analysed by geographic region the data revealed two distinct patterns: homicide and suicide rates were positively correlated in European countries (rho = 0.89, P0.0001), but negatively correlated in the Asia Pacific Region (rho = -0.97, P0.0001), and the Americas (rho = -0.62, P0.005).The strength and direction of the relationship between homicide and suicide vary significantly with geographic region. The divergent geographic patterns in the relationship between homicide and suicide might be due to regional differences in social and cultural variables.

Introduction Since the 2003 peace talks, the Liberian government has made progress in rebuilding a comprehensive national health system. However, the effective referral of patients from one health facility to another remains a challenge, especially in rural areas. The objective of this study is to compare referral care practices at rural and urban health facilities in the most populous county in Liberia. Methods A cross-sectional health referral survey was conducted at a representative sample of primary clinics, health centres and hospitals in Montserrado County, Liberia. The survey was administered via direct interview with a qualified director of each health facility by a single observer. The survey describes baseline facility data, characteristics of referrals, referral guidelines used, transport modes and communication methods. Referral processes were compared between rural and urban health facilities. Results During the 6-week study, 62 health facilities were surveyed. Most facilities were considered urban ( n = 52, 84%). Average patient presentations to rural outpatient and inpatient health facilities during the 3-months prior to the study period was 3182.8 and 42.4, respectively, compared to 2559.0 and 866.8 at urban outpatient and inpatient facilities. The mean percent of referred patients at rural health facilities was 51.8% compared to 10.7% at urban facilities ( p = 0.004). The mean overall distance to the referred health facility ( p = 0.025), and cost of taxi transfer was greater among rural health facilities ( p = 0.093). Conclusions Patient referral systems in Liberia are relatively unsystematic. While formal and informal mechanisms for referrals exist at both rural and urban health facilities, establishing guidelines for referral care practices and transportation strategies tailored to each of these settings will help to strengthen the healthcare system as a whole.