Search

Introduction Paediatric emergency medicine (PEM) is poorly developed in low and middle-income countries. The magnitude of challenges facing Paediatric Emergency Departments (PEDs) in Nigeria has not been well described. This study aimed to assess paediatric emergency care preparedness across PEDs in Nigeria. Methods This was a prospective cross-sectional study that utilized a self-administered questionnaire and a check list to assess three key domains (managerial, medication and equipment) in tertiary care PED facilities that were recruited across Nigeria. Preparedness scores and other institutional attributes were compared between zones and regions. Results Thirty-four tertiary-level PEDs across Nigeria were included. The mean number of patient visits over the 30-day period prior to data collection was 253.2 (±261.2). The mean (SD) managerial, medication and equipment performance scores of the included PEDs were 42.9% (±14.3%), 50.7% (±22.3%) and 43.9% (±11.8%) respectively. The mean (SD) total performance score was 46.9% (±15.3%). Only 13 PEDs had a total performance score of >50%. There was a statistically significant higher mean equipment score (p = 0.029) in the Southern region (47.6 ± 3.1) compared to the Northern region (38.9 ± 2.3) of the country. Conclusions This study reports a global but remediable deficiency in emergency care preparedness amongst PEDs in tertiary care facilities in Nigeria. This study highlights the need for training of PED managers in basic and advanced life support and for the improvement in medication and equipment procurement across Nigeria.

Background Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. Methods We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. Results 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. Conclusion One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.

IntroductionMuch is known around public health preparedness and response phases. However, between the two phases is operational readiness that comprises the immediate actions needed to respond to a developing risk or hazard. Currently, emergency readiness is embedded in multiple frameworks and policy documents related to the health emergency cycle. However, knowledge about operational readiness’ critical readiness components and actions required by countries to respond to public health eminent threat is not well known. Therefore, we aim to define and identify the critical elements of ‘operational readiness’ for public health emergencies, including COVID-19, and identify lessons learnt from addressing it, to inform the WHO Operational Readiness Framework.Methods and analysisThis is a scoping review following the Joanna Briggs Institute guidance. Reporting will be according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, Embase and Web of Science databases and grey literature will be searched and exported into an online systematic review software (eg, Rayyan in this case) for review. The review team, which apart from scoping review methodological experts include content experts in health systems and public health and emergency medicine, prepared an a priori study protocol in consultation with WHO representatives. ATLAS.ti V.9 will be used to conduct thematic data analysis as well as store, organise and retrieve data. Data analysis and presentation will be carried out by five reviewers.Ethics and disseminationThis review will reveal new insights, knowledge and lessons learnt that will translate into an operational framework for readiness actions. In consultation with WHO, findings will be disseminated as appropriate (eg, through professional bodies, conferences and research papers). No ethics approvals are required as no humans will be involved in data collection.Protocol registrationThis rapid scoping review has been registered on Open Science Framework (doi:10.17605/OSF.IO/6SYAH).

This is the twelfth version (eleventh update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline.What is the role of drugs in the treatment of patients with covid-19?The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and under way. The emerging SARS-CoV-2 variants (such as omicron) and subvariants are also changing the role of therapeutics. This update provides updated recommendations for remdesivir, addresses the use of combination therapy with corticosteroids, interleukin-6 (IL-6) receptor blockers, and janus kinase (JAK) inhibitors in patients with severe or critical covid-19, and modifies previous recommendations for the neutralising monoclonal antibodies sotrovimab and casirivimab-imdevimab in patients with non-severe covid-19.• Remdesivir: a conditional recommendation for its use in patients with severe covid-19; and a conditional recommendation against its use in patients with critical covid-19. • Concomitant use of IL-6 receptor blockers (tocilizumab or sarilumab) and the JAK inhibitor baricitinib: these drugs may now be combined, in addition to corticosteroids, in patients with severe or critical covid-19. • Sotrovimab and casirivimab-imdevimab: strong recommendations against their use in patients with covid-19, replacing the previous conditional recommendations for their use.When moving from new evidence to updated recommendations, the Guideline Development Group (GDG) considered a combination of evidence assessing relative benefits and harms, values and preferences, and feasibility issues. For remdesivir, new trial data were added to a previous subgroup analysis and provided sufficiently trustworthy evidence to demonstrate benefits in patients with severe covid-19, but not critical covid-19. The GDG considered benefits of remdesivir to be modest and of moderate certainty for key outcomes such as mortality and mechanical ventilation, resulting in a conditional recommendation. For baricitinib, the GDG considered clinical trial evidence (RECOVERY) demonstrating reduced risk of death in patients already receiving corticosteroids and IL-6 receptor blockers. The GDG acknowledged that the clinical trials were not representative of the world population and that the risk-benefit balance may be less advantageous, particularly in patients who are immunosuppressed at higher risk of opportunistic infections (such as serious fungal, viral, or bacteria), those already deteriorating where less aggressive or stepwise addition of immunosuppressive medications may be preferred, and in areas where certain pathogens such as HIV or tuberculosis, are of concern. The panel anticipated that there would be situations where clinicians may opt for less aggressive immunosuppressive therapy or to combine medications in a stepwise fashion in patients who are deteriorating. The decision to combine the medications will depend on their availability, and the treating clinician's perception of the risk-benefit balance associated with combination immunosuppressive therapy, particularly in patient populations at risk of opportunistic infections who may have been under-represented in clinical trials. When making a strong recommendation against the use of monoclonal antibodies for patients with covid-19, the GDG considered in vitro neutralisation data demonstrating that sotrovimab and casirivimab-imdevimab evaluated in clinical trials have meaningfully reduced neutralisation activity of the currently circulating variants of SARS-CoV-2 and their subvariants. There was consensus among the panel that the absence of in vitro neutralisation activity strongly suggests absence of clinical effectiveness of these monoclonal antibodies. However, there was also consensus regarding the need for clinical trial evidence in order to confirm clinical efficacy of new monoclonal antibodies that reliably neutralise the circulating strains in vitro. Whether emerging new variants and subvariants might be susceptible to sotrovimab, casirivimab-imdevimab, or other anti-SARS-CoV-2 monoclonal antibodies cannot be predicted.• Recommended for patients with severe or critical covid-19—strong recommendations for systemic corticosteroids; IL-6 receptor blockers (tocilizumab or sarilumab) in combination with corticosteroids; and baricitinib as an alternative to IL-6 receptor blockers, in combination with corticosteroids. • Recommended for patients with non-severe covid-19 at highest risk of hospitalisation—a strong recommendation for nirmatrelvir/ritonavir; conditional recommendations for molnupiravir and remdesivir. • Not recommended for patients with non-severe covid-19—a conditional recommendation against systemic corticosteroids; a strong recommendation against convalescent plasma; a recommendation against fluvoxamine, except in the context of a clinical trial; and a strong recommendation against colchicine. • Not recommended for patients with non-severe covid-19 at low risk of hospitalisation—a conditional recommendation against nirmatrelvir/ritonavir. • Not recommended for patients with severe or critical covid-19—a recommendation against convalescent plasma except in the context of a clinical trial; and a conditional recommendation against the JAK inhibitors ruxolitinib and tofacitinib. • Not recommended, regardless of covid-19 disease severity—a strong recommendations against hydroxychloroquine and against lopinavir/ritonavir; and a recommendation against ivermectin except in the context of a clinical trial.This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact.Recommendations on anticoagulation are planned for the next update to this guideline.

Clinical question What is the role of drugs in preventing covid-19? Why does this matter? There is widespread interest in whether drug interventions can be used for the prevention of covid-19, but there is uncertainty about which drugs, if any, are effective. Recommendations The second version of this living guideline reiterates the previous strong recommendation against the use of hydroxychloroquine and includes a new conditional recommendation against the use of tixagevimab-cilgavimab in individuals who do not have covid-19. How this guideline was created This living guideline is from the World Health Organization (WHO) and provides up to date covid-19 guidance to inform policy and practice worldwide. Magic Evidence Ecosystem Foundation (MAGIC) provides methodological support. A living systematic review with network analysis informs the recommendations. An international guideline development group (GDG) of content experts, clinicians, patients, an ethicist and methodologists produces recommendations following standards for trustworthy guideline development using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Understanding the recommendations The living network meta-analysis informing this guideline included 12 trials (8379 participants) comparing hydroxychloroquine to standard care/placebo, and one trial (5197 participants) comparing tixagevimab-cilgavimab to standard care/placebo. When moving from evidence to the continued strong recommendation against the use of hydroxychloroquine, the GDG emphasised additional evidence suggesting no or little effect on mortality and hospital admission, and an increased risk of adverse effects. For the new conditional recommendation against the use of tixagevimab-cilgavimab, the GDG emphasised in vitro evidence reducing the applicability of available trial data. While trial results demonstrated modest reduction in the occurrence of laboratory confirmed symptomatic covid-19, lack of in vitro neutralisation of new SARS-CoV-2 sub-lineages was considered to have rendered these results obsolete. Updates This is a living guideline. New recommendations will be published in this article and signposted by update notices to this guideline. Readers note This is the second version of the living guideline for drugs to prevent covid-19. It complements the WHO living guideline on drugs to treat covid-19 and living guidance regarding covid-19 related clinical management. When citing this article, please consider adding the update number and date of access for clarity.

Background Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Introduction International emergency medicine is a new subspecialty within emergency medicine. International emergency medicine (EM) fellowships have been in existence for more than 10 years, but data is limited on the experiences of the fellows. Our goal in this study was to understand the fellowship experience. Methods The study employed a cross-sectional survey in which participants were asked about their demographics, fellowship program, and advanced degree. Participants consisted of former fellows who completed the fellowship between 2010-19. The survey consisted of both closed and open-ended questions to allow for further explanation of former fellows' experience. Descriptive analysis was conducted on the quantitative survey data while content analysis was conducted to ascertain salient themes from the open-ended questions. Results We contacted 71 former fellows, of whom 40 started and 36 completed surveys, for a 51% response rate (55.6% women). Two-year fellowships predominated, with 69.4% of respondents. Prior to fellowship, a subset of fellows spoke the native languages of their service sites: French, Spanish, Haitian Creole, Mandarin, or Kiswahili. Half the respondents spent 26-50% of their fellowship in field work, with 83.3% of institutions providing direct funding for this component. Many respondents stated a need for further institutional support (money or infrastructure) for fieldwork and mentoring. Non-governmental organizations comprised 29.7% of respondents' work partners, while 28.6% were with academic institutions in country, focused mostly on education, health systems development, and research. The vast majority (92%) of respondents continued working in global EM, with the majority based in American academic institutions. Those who did not cited finances and lack of institutional support as main reasons. Conclusion This study describes the fellow experience in international EM. The majority of fellows completed a two-year fellowship with 26-50% of their time spent in fieldwork with 83.3% of institutions providing funding. The challenges in pursuing a long-term career in global EM included the cost of international work, inadequate mentorship, and departmental funding.

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.

Clinical questionWhat is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020.Current practiceRemdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice.RecommendationsThe guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir.How this guideline was createdAn international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems.The evidenceThe linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay.Understanding the recommendationMost patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.

Background: Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings. Objective: To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships. Methods: An electronic search was conducted using four databases for manuscripts on EM training programs – defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care – developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted. Findings: Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding. Conclusions: Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.

Background First aid training is a cost-effective way to decrease the burden of disease and injury in low- and middle-income countries (LMIC). Since evidence from Western countries has shown that children are able to learn first aid, first aid training of children in LMIC may be a promising way forward. Hence, our project aim was to develop evidence-based contextualized materials to train Sub-Saharan African children in first aid. Methods Systematic literature searches were conducted to identify studies on first aid education to children up to 18 years old (research question one), and studies investigating different teaching approaches (broader than first aid) in LMIC (research question two). A multidisciplinary expert panel translated the evidence to the context of Sub-Saharan Africa, and evidence and expert input were used to develop teaching materials. Results For question one, we identified 58 studies, measuring the effect of training children in resuscitation, first aid for skin wounds, poisoning etc. For question two, two systematic reviews were included from which we selected 36 studies, revealing the effectiveness of several pedagogical methods, such as problem-solving instruction and small-group instruction. Expert input was useful for placing the evidence against the African context. Conclusions The above approach resulted in an educational pathway (i.e. a scheme with educational goals concerning first aid for different age groups), a list of recommended educational approaches, and evidence-based first aid teaching materials for children, adapted to the African context.

Background First aid training is a cost-effective way to decrease the burden of disease and injury in low- and middle-income countries (LMIC). Since evidence from Western countries has shown that children are able to learn first aid, first aid training of children in LMIC may be a promising way forward. Hence, our project aim was to develop contextualized materials to train sub-Saharan African children in first aid, based on the best available evidence. Methods Systematic literature searches were conducted to identify studies on first aid education to children up to 18 years old (research question one), and studies investigating different teaching approaches (broader than first aid) in LMIC (research question two). A multidisciplinary expert panel translated the evidence to the context of sub-Saharan Africa, and evidence and expert input were used to develop teaching materials. Results For question one, we identified 58 studies, measuring the effect of training children in resuscitation, first aid for skin wounds, poisoning etc. For question two, two systematic reviews were included from which we selected 36 studies, revealing the effectiveness of several pedagogical methods, such as problem-solving instruction and small-group instruction. However, the certainty of the evidence was low to very low. Hence expert input was necessary to formulate training objectives and age ranges based on “good practice” whenever the quantity or quality of the evidence was limited. The experts also placed the available evidence against the African context. Conclusions The above approach resulted in an educational pathway (i.e. a scheme with educational goals concerning first aid for different age groups), a list of recommended educational approaches, and first aid teaching materials for children, based on the best available evidence and adapted to the African context.

BackgroundFrontline providers around the world deliver emergency care daily, often without prior dedicated training. In response to multiple country requests for open-access, basic emergency care training materials, the World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), undertook development of a course for health care providers-Basic Emergency Care: Approach to the acutely ill and injured (BEC). As part of course development, pilots were performed in Uganda, the United Republic of Tanzania, and Zambia to evaluate course feasibility and appropriateness. Here we describe participant and facilitator feedback and pre- and post-course exam performance.MethodsA mixed methods research design incorporated pre- and post-course surveys as well as participant examination results to assess the feasibility and utility of the course, and knowledge transfer. Quantitative data were analyzed using Stata, and simple descriptive statistics were used to describe participant demographics. Survey data were coded and grouped by themes and analyzed using ATLAS.ti.ResultsPost-course test scores showed significant improvement (p-value < 0.05) as compared to pre-course. Pre- and post-course questionnaires demonstrated significantly increased confidence in managing emergency conditions. Participant-reported course strengths included course appropriateness, structure, language level and delivery methods. Suggested changes included expanding the 4-day duration of the course.ConclusionThis pilot demonstrates that a low-fidelity, open-access course taught by local instructors can be successful in knowledge transfer. The BEC course was well-received and deemed context-relevant by pilot facilitators and participants in three East African countries. Further studies are needed to evaluate this course's impact on clinical practice and patient outcomes.

Emergency Medicine (EM) residency programmes are new to Africa and exist in only a handful of countries. There has been no follow up on faculty development needs nor training of these graduates since they completed their programmes. The African Federation for Emergency Medicine (AFEM) aims to explore the needs of recent EM graduates with respect to the need for resources, mentorship, and teaching in order to develop a focused African faculty development intervention.As part of the AFEM annual survey, all those who have graduated since 2012 from a Sub-Saharan African EM residency programme were approached. These included Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, Addis Ababa University (AAU) in Ethiopia, Komfo Anokye Teaching Hospital (KATH) in Ghana, the University of Cape Town (UCT) in South Africa, the University of Pretoria (UP) in South Africa, the University of Witswatersrand (Wits) in South Africa, and the University of KwaZulu-Natal (UKZN) in South Africa.The 47 respondents rated themselves as most confident medical experts in knowledge, procedural skills, and communication. Overall graduates felt least equipped as scholars and managers, and requested more educational materials. They reported that the best way for AFEM to support them is through emergency care advocacy and support for their advocacy activities and that their most critical development need is for leadership development, including providing training materials.Recent graduates report that the best ways for AFEM to help new EM graduates is to continue advocacy programmes and the development of leadership and mentorship programmes. However, there is also a demand from these graduates for educational materials, especially online.Les programmes d’internat en médecine d’urgence (MU) sont nouveaux en Afrique et n’existent que dans quelques pays. Aucun suivi n’a été constaté sur les besoins en formation des enseignants ni sur la formation de ces diplômés depuis le moment où ils ont achevé leur cursus. La Fédération africaine de médecine d’urgence (AFEM) s’est donné pour objectif d’étudier les besoins des diplômés récents en MU en termes de besoins en ressources, en mentorat et en enseignement dans le but d’élaborer une intervention en matière de formation ciblée des enseignants en Afrique.Dans le cadre de l’enquête annuelle de l’AFEM, tous les étudiants issu d’un programme d’internat de MU en Afrique subsaharienne qui ont obtenu un diplôme depuis 2012 ont été contactés. Les établissements incluaient l’Université Muhimbili de la santé et des sciences connexes (MUHAS) en Tanzanie, l’Université d’Addis-Abeba (AAU) en Éthiopie, l’Hôpital universitaire Komfo Anokye (KATH) au Ghana, l’Université du Cap (UCT) en Afrique du Sud, l’Université de Pretoria (UP) en Afrique du Sud, l’Université du Witwatersrand (Wits) en Afrique du Sud et l’Université du KwaZulu-Natal (UKZN) en Afrique du Sud.Les 47 personnes interrogées se sont évaluées comme étant totalement confiantes en tant qu’experts médicaux dans les domaines des connaissances, des compétences procédurales et de la communication. Dans l’ensemble, les diplômés s’estimaient moins bien équipés que les universitaires et les gestionnaires, et ont demandé plus de matériel éducatif. Ils ont signalé que, pour l’AFEM, les meilleures façons de les soutenir étaient par le plaidoyer en matière de soins d’urgence et le soutien à leurs activités de plaidoyer, et que leur besoin en développement le plus essentiel est un développement du leadership, notamment en fournissant du matériel de formation.Les diplômés récents signalent que, pour l’AFEM, la meilleure façon d’aider les nouveaux diplômés en MU est la poursuite des programmes de plaidoyer ainsi que du développement des programmes de leadership et de mentorat. Cependant, il existe également une demande de la part de ces diplômés en matière de matériel éducatif, en particulier en ligne.

Background: Given the frequency of suicidal patients making attempts prior to a completed suicide, emergency access to mental health care services could lead to significant reduction in morbidity and mortality for these patients. Aim: To describe the attitudes of prehospital providers and describe transport decision-making around the management of patients with a suicide attempt. Setting: Cape Town Metropole. Methods: A cross-sectional, vignette-based survey was used to collect data related to training and knowledge of the Mental Health Care Act , prehospital transport decision-making and patient management. Results: Patients with less dramatic suicidal history were more likely to be discharged on scene. Few respondents reported the use of formal suicide evaluation tools to aid their decision. Respondents displayed negative attitudes towards suicidal patients. Some respondents reported returning to find a suicidal patient dead, while others reported patient attempts at suicide when in their care. Eighty per cent of respondents had no training in the management of suicidal patients, while only 7.0% had specific training in the Mental Health Care Act . Conclusion: A critical lack in the knowledge, training and implementation of the Mental Health Care Act exists amongst prehospital providers within the Western Cape. A further concern is the negative feelings towards suicidal patients and the lack of commitment to transporting patients to definitive care. It is essential to urgently develop training programmes to ensure that prehospital providers are better equipped to deal with suicidal patients.

Despite the frequency and severity of burns in Low Income Countries, including many in Africa, there is a paucity of research and funding for these populations to aid in prevention, treatment and recovery of burn patients. The objectives of this paper are four-fold. First, by addressing the pathophysiology of burns the reader may strengthen understanding of the clinical progression of burns. Second, through describing proper assessment of burn patients one will learn how to decide if patients can be discharged, admitted or transferred to burn centre. Third, the inclusion of treatments solidifies the steps necessary to manage a patient in a hospital setting. Lastly, the overall goal of the paper, is to raise awareness that more research, publication and funding is required to create a better understanding of burns in Africa and why they continue to be devastating social and economic burdens.

Background Emergency medicine (EM) training programmes are being conducted around the world but no study has assessed the procedural competence of developing nations9 EM trainees. Objectives To quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa9s first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa. Methods All 30 graduates from the first four classes in the UCT/SUN EM programme (2007–10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics. Results Twenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations. Conclusions EM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

ACADEMIC EMERGENCY MEDICINE 2011; 18:868–871 © 2011 by the Society for Academic Emergency Medicine Abstract Africa’s first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the program’s first 7 years that may help advise other nascent training programs in developing countries.

Objectives To describe the case mix, interventions, procedures and management of patients in public emergency departments (ED) in Kenya. Methods An observational study over 24 h, of patients who presented to 15 public ED during the 3-month period from 1 October to 31 December 2010. The study was conducted across Kenya in two national referral hospitals, five secondary level hospitals and eight primary level hospitals. All patients presenting alive to the ED during the 24-h study period that were seen by a doctor or clinical officer were included in the study. A data collection form was completed by the primary investigator at the time of the initial ED consultation documenting patient demographics, presenting complaints, investigations ordered, procedures done, initial diagnosis and outcome of ED consultation. Results Data on 1887 patient presentations were described. Adults ($13 years) accounted for the majority (70%) of patients. Two peak age groups, 0e9 and 20e29 years, accounted for 27% and 25% of patients, respectively. Respiratory and trauma presentations each accounted for 21% of presentations, with a wide spread of other presentations. Over half (58%) of the patients were investigated in the department. 385 patients received immediate treatment in the ED before discharge. Fewer than one in three patients admitted or transferred to specialist units received any therapy in the ED. Conclusions ED in Kenya provide care to an undifferentiated patient population yet most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients have to await transfer to wards or specialist units to start receiving treatment.

Summary Background Timely access to emergency care can substantially reduce mortality. International benchmarks for access to emergency hospital care have been established to guide ambitions for universal health care by 2030. However, no Pan-African database of where hospitals are located exists; therefore, we aimed to complete a geocoded inventory of hospital services in Africa in relation to how populations might access these services in 2015, with focus on women of child bearing age. Methods We assembled a geocoded inventory of public hospitals across 48 countries and islands of sub-Saharan Africa, including Zanzibar, using data from various sources. We only included public hospitals with emergency services that were managed by governments at national or local levels and faith-based or non-governmental organisations. For hospital listings without geographical coordinates, we geocoded each facility using Microsoft Encarta (version 2009), Google Earth (version 7.3), Geonames, Fallingrain, OpenStreetMap, and other national digital gazetteers. We obtained estimates for total population and women of child bearing age (15–49 years) at a 1 km2 spatial resolution from the WorldPop database for 2015. Additionally, we assembled road network data from Google Map Maker Project and OpenStreetMap using ArcMap (version 10.5). We then combined the road network and the population locations to form a travel impedance surface. Subsequently, we formulated a cost distance algorithm based on the location of public hospitals and the travel impedance surface in AccessMod (version 5) to compute the proportion of populations living within a combined walking and motorised travel time of 2 h to emergency hospital services. Findings We consulted 100 databases from 48 sub-Saharan countries and islands, including Zanzibar, and identified 4908 public hospitals. 2701 hospitals had either full or partial information about their geographical coordinates. We estimated that 287 282 013 (29·0%) people and 64 495 526 (28·2%) women of child bearing age are located more than 2-h travel time from the nearest hospital. Marked differences were observed within and between countries, ranging from less than 25% of the population within 2-h travel time of a public hospital in South Sudan to more than 90% in Nigeria, Kenya, Cape Verde, Swaziland, South Africa, Burundi, Comoros, São Tomé and Príncipe, and Zanzibar. Only 16 countries reached the international benchmark of more than 80% of their populations living within a 2-h travel time of the nearest hospital. Interpretation Physical 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. Funding Wellcome Trust and the UK Department for International Development.

Background. Emergency medicine (EM) is a relatively new, but growing medical specialty in sub-Saharan Africa. African EM training programmes have used small-group learning (SGL) modalities in their curricula. However, there is little knowledge of whether SGL modalities are perceived to be effective in these African EM training programmes.Objectives. To investigate the acceptability of SGL for physicians’ training in an academic Tanzanian emergency department using a novel EM curriculum.Methods. Using responses to a written questionnaire, we explored the perceived effectiveness of SGL compared with traditional didactic lectures among 38 emergency department physician learners in Dar es Salaam, Tanzania. Perceptions of SGL were identified from qualitative responses, and regression analyses were used to determine strength of association between quantitative outcomes.Results. Reported benefits of SGL included team building, simulation training, enhancement of procedural skills, and the opportunity to discuss opinions on clinical management. SGL scored more favourably with regard to improving clinical practice, enjoyment of learning, and building peer-to-peer relations. Lectures scored more favourably at improving medical knowledge. Preference towards SGL over lectures for overall training increased with years of clinical experience (95% confidence interval (CI) 0.16 - 0.62, p=0.002, Spearman’s rho 0.51), and the perception that SGL reinforces learner-teacher relationships correlated with seniority within residency training (95% CI 0.14 - 0.86, p=0.007, Spearman’s rho 0.47).Conclusion. Techniques of SGL were perceived as effective at improving clinical practice in the emergency department setting. These modalities may be more favourably accepted by more experienced physician learners – therefore, new EM teaching programmes in Africa should consider these factors when targeting educational strategies for their respective regions and learner cohorts.

Backgound. Prevention of hypoxia and thus secondary brain injury in traumatic brain injury (TBI) is critical. However there is controversy regarding the role of endotracheal intubation in the prehospital management of TBI. Objective. To describe the outcome of TBI with various airway management methods employed in the prehospital setting in the Cape Town Metropole. Methods. The study was a cohort descriptive observational analysis of 124 consecutively injured adult patients who were admitted for severe TBI (Glasgow Coma Score ≤8) to Groote Schuur and Tygerberg hospitals between 1 January 2009 and 31 August 2011. Patients were categorised by their method of airway management: rapid sequence intubation (RSI), sedation-assisted intubation, failed intubation, basic airway management, and intubated without drugs. Good outcomes were defined by a Glasgow Outcome Score of 4 - 5. Results. There was a statistically significant association between airway management and outcome (p=0.013). Patients who underwent basic airway management had a higher proportion of a good outcome (72.9%) than patients who were intubated in the prehospital setting. A good outcome was observed with 61.8% and 38.4% of patients who experienced sedation-assisted intubation and RSI, respectively. Patients intubated without drugs had the poorest outcome (88%), followed by rapid sequence intubation (61.5%) and by the sedation assisted group (38.2%). Conclusion. Prehospital intubation did not demonstrate improved outcomes over basic airway management in patients with severe TBI. A large prospective, randomised trial is warranted to yield some insight into how these airway interventions influence outcome in severe TBI.

Objective:Africa's first postgraduate training program in emergency medicine (EM) was established at the University of Cape Town/Stellenbosch University (UCT/SUN) in 2004. This study of the UCT/SUN EM program investigated the backgrounds, perceptions, and experiences of its graduates.Methods:This was a cross-sectional descriptive study. The study population was the 30 graduates from the first four classes in the UCT/SUN EM program (2007–2010). We employed a scripted interview with a combination of closed and open-ended questions. Data were analyzed using the thematic method of qualitative analysis.Results:Twenty-seven (90%) graduates were interviewed. Initial career goals were primarily (78%) to practice EM in a nonacademic clinical capacity. At the time of the interview, 52% held academic positions, 15% had nonacademic clinical positions, and 33% had temporary positions and were looking for other posts. The three most commonly cited strengths of their program were diversity of clinical rotations (85%), autonomy and procedural experience (63%), and importance of being pioneers within Africa (52%). The three most commonly cited weaknesses were lack of bedside teaching in the ED (96%), lack of career options after graduation (74%), and lack of preparation for academic careers (70%).Conclusions:The lessons identified from structured interviews with graduates from Africa’s first EM training include the importance of strong clinical training, difficulty of ensuring bedside teaching in a new program, the necessity of ensuring postgraduation positions, and the need for academic training. These findings may be useful for other developing countries looking to start EM training programs.

OBJECTIVES: To determine the current door-to-needle time for the administration of fibrinolytics for acute myocardial infarction (AMI) in emergency centres (ECs) at three hospitals in Cape Town, and to compare it with the American Heart Association/American College of Cardiology (AHA/ACC) recommendation of 30 minutes as a marker of quality of care. METHODS: A retrospective review of case notes from January 2008 to July 2010 of all patients receiving thrombolytics for AMI in the ECs of three Cape Town hospitals. The total door-to-needle time was calculated and patient demographics and presentation, physician qualification, clinical symptomology and reasons for delays in thromobolytic administration were analysed. RESULTS: A total of 372 patients with acute ST elevation myocardial infarction (STEMI) were identified; 161 patients were eligible for the study. The median door-to-needle time achieved was 54 minutes (range 13 - 553 mins). A door-to-needle time of 30 minutes or less was achieved in 33 (20.5%) patients; 51.3% of the patients arrived by ambulance; 34% of patients had a pre-hospital 12-lead ECG; and 88.8% had typical symptoms of myocardial infarction. Medical officers administered thrombolytics to 44.7% of the patients. The predominant infarct location on ECG was inferior (55.9%). CONCLUSION: A significant number of patients were not thrombolysed within 30 minutes of presentation. The lack of senior doctors, difficulty interpreting ECGs, atypical presentations and EC system delays prolonged the door-to-needle time in this study.

To determine the current door-to-needle time for the administration of fibrinolytics for acute myocardial infarction (AMI) in emergency centres (ECs) at three hospitals in Cape Town, and to compare it with the American Heart Association/American College of Cardiology (AHA/ACC) recommendation of 30 minutes as a marker of quality of care.A retrospective review of case notes from January 2008 to July 2010 of all patients receiving thrombolytics for AMI in the ECs of three Cape Town hospitals. The total door-to-needle time was calculated and patient demographics and presentation, physician qualification, clinical symptomology and reasons for delays in thromobolytic administration were analysed.A total of 372 patients with acute ST elevation myocardial infarction (STEMI) were identified; 161 patients were eligible for the study. The median door-to-needle time achieved was 54 minutes (range 13 - 553 mins). A door-to-needle time of 30 minutes or less was achieved in 33 (20.5%) patients; 51.3% of the patients arrived by ambulance; 34% of patients had a pre-hospital 12-lead ECG; and 88.8% had typical symptoms of myocardial infarction. Medical officers administered thrombolytics to 44.7% of the patients. The predominant infarct location on ECG was inferior (55.9%).A significant number of patients were not thrombolysed within 30 minutes of presentation. The lack of senior doctors, difficulty interpreting ECGs, atypical presentations and EC system delays prolonged the door-to-needle time in this study.

Our study suggests that routine laboratory screening provides no additional information to that obtained from a thorough history and clinical examination in patients at high risk of having an underlying medical cause of presenting psychotic symptoms.

To evaluate four paediatric weight estimation methods (APLS, Luscombe and Owens, Best Guess and Broselow tape) in order to determine which are accurate for weight estimation in South African children.From a database of 2832 children aged 1-10 years seen at Red Cross Hospital in Cape Town, measured weight was compared to estimated weights from all four methods.APLS formula and the Broselow Tape showed the best correlation with measured weight. Mean error was 3.3% for APLS (for 1-10-year olds) and 0.9% for Broselow tape (children145 cm length and35 kg). Both the Best Guess and Luscombe and Owens formulae tended to overestimate weight (15.4% and 12.4%, respectively).The Broselow tape and APLS estimation methods are most accurate in estimating weight in the Western Cape paediatric population, even though they have a small tendency to underestimate weight. Clinicians need to bear in mind that none of the formulae are infallible and constant reassessment and clinical judgement should be used, as well as a measured weight as soon as possible in an emergency situation.