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Strengthening Emergency Care Knowledge and Skills in Uganda

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Strengthening Emergency Care Knowledge and Skills in Uganda Original research Emerg Med J: first published as 10.1136/emermed-2020-209718 on 14 April 2021. Downloaded from Strengthening emergency care knowledge and skills in Uganda and Tanzania with the WHO- ICRC Basic Emergency Care Course Sean M Kivlehan ,1 Julia Dixon ,2 Joseph Kalanzi,3 Hendry R Sawe ,4 Emily Chien,5 Jordan Robert,6 Lee Wallis ,6 Teri A Reynolds7 Handling editor Richard Body ABSTRACT Key messages Background There is a pressing need for emergency ► Additional supplemental material is published online care (EC) training in low- resource settings. We assessed only. To view please visit the the feasibility and acceptability of training frontline What is already known on this subject journal online (http:// dx. doi. healthcare providers in emergency care with the World ► There is a significant need for emergency care org/ 10. 1136/ emermed- 2020- Health Organization (WHO)- International Committee in low- resource settings, where people suffer 209718). of the Red Cross (ICRC) Basic Emergency Care (BEC) from lack of access to timely care and high For numbered affiliations see Course using a training- of- trainers (ToT) model with local rates of mortality. Many courses aiming to end of article. providers. train providers in these settings are limited by Methods Quasiexperimental pretest and post- test availability of trainers, equipment or cost. Correspondence to study of an educational intervention at four first- level Dr Sean M Kivlehan, Emergency What this study adds Medicine, Brigham and district hospitals in Tanzania and Uganda conducted in ► This quasiexperimental pretest and post- test Women’s Hospital, Boston MA March and April of 2017. A 2- day ToT course was held 02115, USA; in both Tanzania and Uganda. These were immediately study suggests that the WHO-ICRC Basic smkivlehan@ bwh. harvard. edu followed by a 5- day BEC Course, taught by the newly Emergency Care course can be implemented trained trainers, at two hospitals in each country. Both in low- resource settings by locally trained An early version of this providers with local equipment at a low cost. manuscript was published as a prior to and immediately following each training, preprint at https:// doi. org/ 10. participants took assessments on EC knowledge and 21203/ rs. 2. 19074/ v1. rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants and middle- income countries (LMICs), and patients Received 3 April 2020 was collected and summarised. in LMICs suffer the highest rates of mortality from Revised 21 March 2021 acute complications of chronic diseases.2 3 Overall, Accepted 25 March 2021 Results Fifty-nine participants completed the four BEC Courses. All participants were current healthcare workers 54% of annual deaths in LMICs could be poten- tially addressed by emergency care (EC), suggesting at the selected hospitals. An additional 10 participants 4 http://emj.bmj.com/ completed a ToT course. EC knowledge scores were an opportunity to improve these outcomes. Recog- significantly higher for participants immediately following nising this need, the World Health Assembly Resolu- tion 72.16 called for increased efforts to strengthen the training compared with their scores just prior to the 5 training when assessed across all study sites (Z=6.23, the provision of EC, including training. p<0.001). Across all study sites, mean EC confidence Improving patient outcomes for emergency medical conditions requires several conditions to ratings increased by 0.74 points on a 4- point Likert be met including: patient awareness of an emer- scale (95% CI 0.63 to 0.84, p<0.001). Main qualitative on September 25, 2021 by guest. Protected copyright. feedback included: positive reception of the sessions, gency medical condition, ability to seek emergency medical care, access to a medical facility capable of especially hands- on skills; request for additional BEC providing EC and high- quality care in the emer- trainings; request for obstetric topics; and need for more 6 7 allotted training time. gency unit. Patients in LMICs face barriers within Conclusions Implementation of the WHO- ICRC each of these conditions. Emergency service utilisa- BEC Course by locally trained providers was feasible, tion rates are extremely low in low- income coun- tries (8 per 1000 population) when compared with acceptable and well received at four sites in East Africa. 8 Participation in the training course was associated with high-income countries (264 per 1000 population). a significant increase in EC knowledge and confidence In one review, 192 emergency facilities were iden- tified in 59 LMICs; in the USA alone, there are at all four study sites. The BEC is a low- cost intervention 9 © Author(s) (or their that can improve EC knowledge and skill confidence roughly 5000 emergency facilities. Utilisation and employer(s)) 2021. Re- use across provider cadres. access to a health facility does not guarantee access permitted under CC BY- NC. No to quality EC. Overall mortality rates have been commercial re- use. See rights and permissions. Published estimated to be extremely high in LMIC emergency by BMJ. units (EUs): 1.8% as compared with 0.04% in the INTRODUCTION USA.9 10 Paediatric mortality in LMIC EUs has been To cite: Kivlehan SM, Every day, people seek care for health emergen- estimated to be even higher at 4.8%.9 Quality of Dixon J, Kalanzi J, et al. Emerg Med J Epub ahead cies. Over 50% of mortality worldwide can be care can be poor due to a lack of resources and vari- 1 11 of print: [please include Day attributed to emergency medical conditions. In ability in provider training. Month Year]. doi:10.1136/ low-resource settings, the need is particularly great: In order to strengthen EC delivery in resource- emermed-2020-209718 90% of injury related deaths occur in low-income limited settings, the World Health Organization Kivlehan SM, et al. Emerg Med J 2021;0:1–7. doi:10.1136/emermed-2020-209718 1 Original research Emerg Med J: first published as 10.1136/emermed-2020-209718 on 14 April 2021. Downloaded from (WHO), in collaboration with the International Committee of Outcome variables the Red Cross (ICRC) and the International Federation for Emer- A multimethod approach was used to evaluate implementa- gency Medicine (IFEM), developed the Basic Emergency Care tion including an assessment, confidence ratings and feedback (BEC) course in 2015, a 5- day intensive training course covering surveys. These evaluative tools and their content were developed core EC content, including didactics, practical skills and small by the WHO and are a standardised part of the BEC Course groups.12 Participants are taught a systematic (ABCDE) approach package. R V.4.0.1 was used for all statistical analyses; code to use for every patient encounter and review signs and symp- available on request.13 toms and management of life-threatening conditions during the chief complaint- based modules: shock, trauma, difficulty EC knowledge score in breathing, and altered mental status. Content is delivered via Each participant completed a 25- question multiple choice assess- didactics and small group exercises. A significant portion of the ment immediately prior to and following the course covering course is dedicated to practical skills stations that re- emphasise core concepts in BEC. The Wilcoxon sign-ranked test was used, the systematic ABCDE approach. The course is designed to be due to non- normality, to assess the difference in the median taught by local providers who have previously taken the course number of questions answered correctly (called EC knowledge and attended an additional 2-day train-the- trainer course after score) for each participant on the assessments completed before completing the BEC. Here, we describe an early implementation and after the training. The data are matched by participant. of the BEC Course in two East African countries using a train- the- trainer model. EC confidence rating Each participant also completed a confidence rating question- METHODS naire immediately prior to and following the course. Participants Study setting and participants rated their confidence in completing 12 EC actions on a Likert The BEC Course was implemented in two hospitals in Tanzania scale of 1 (least confident) to 4 (most confident) (online supple- and two hospitals in Uganda during March and April of 2017. mental appendix 1). The paired samples t-test was used to assess The implementation was performed with the support of the the difference between the mean confidence rating before and African Federation for Emergency Medicine (AFEM) in collabo- after training. Individual responses were not retained at all study ration with the national emergency medicine societies and Minis- sites, precluding the Wilcoxon sign- ranked test from being used tries of Health of both Tanzania and Uganda. The emergency to calculate medians or to match based on participant. However, medicine society leads in each country participated in the devel- the mean confidence rating for all participants at each of the four opment of the BEC Course and identified participating hospital study sites for each of the 12 EC actions was available and was sites based on their high volume of emergency visits, location on matched by skill and site. major roads and support of hospital leadership. All sites provide EC services, and at all sites these services are delivered in a less Course feedback formal manner than the standard emergency unit staffed by non- Participants completed structured feedback forms immedi- rotating personnel who have received specialised training in ately after each BEC module, each block of skills training and trauma and acute care found in high-income countries. the conclusion of the course. Postcourse qualitative data were The two participating hospitals in Uganda were Kawolo collected as free text and descriptively analysed by frequency http://emj.bmj.com/ District Hospital and Mubende Regional Referral Hospital.
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