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News Improving emergency care in Uganda A low-cost emergency care initiative has halved deaths due to emergency conditions in two district hospitals in Uganda. The intervention is being scaled up nationally. Gary Humphreys reports. Halimah Adam, a nurse at the Mubende countries have no emergency access In Uganda, road traffic crashes are regional referral hospital in Uganda, telephone number to call for an ambu- a matter of particular concern. “Uganda remembers the little boy well. “He was lance, and many countries have no am- has one of the highest incidences of brought into the hospital by his mother,” bulances to call. Hospitals lack dedicated road traffic trauma and deaths on the she says. “He was unconscious and emergency units and have few providers African continent,” says Joseph Ka- barely breathing.” trained in the recognition and manage- lanzi, Senior House Officer, Emergency The mother told Halimah that the ment of emergency conditions. Medicine, Makerere University College boy had drunk paraffin, mistaking it “Over half of deaths in low- and of Health Sciences. “We are faced with for a soft drink. Paraffin (kerosene) is middle-income countries are caused multiple road traffic crashes daily and poorly absorbed by the gastrointestinal by conditions that could be addressed have barely any dedicated emergency tract, but when aspirated, which can by effective emergency care,” says Dr re s p on s e .” happen when a child vomits, it causes Teri Reynolds, an expert in emergency, According to WHO’s Global status lung inflammation, preventing the lungs trauma and acute care at the World report on road safety 2018, road traffic from oxygenating the blood. The little Health Organization (WHO). “Despite crashes resulted in 12 036 deaths in 2016 boy brought to Halimah had vomit all its enormous potential contribution, in Uganda. over his clothes. emergency care has been neglected in Kalanzi has personal experience of Halimah remembers the little boy health system strengthening. It’s a real the problem, having dealt with emer- not because his case was unusual (par- blind spot.” gency cases when he worked in the affin ingestion accounts for roughly Emergency care systems address a Kitovu Hospital in the Masaka District half of accidental child poisonings in wide range of acute conditions, includ- of Uganda in 2010. “People would come Uganda) but because, for the first time, ing those caused by poisonings and oth- in with internal injuries and the best we she knew what to do to save him and er injuries, communicable and noncom- could do was put them on intravenous had the resources required to do it. municable diseases, and complications fluids and bandage their wounds,” he “He was the first person I saved after of pregnancy, but they also enhance the says. “We did not know how to do being trained in the Basic Emergency impact of other health service interven- anything else, and there was no hope of Care course,” she says. “We placed an tions by facilitating early recognition of getting more skills.” oral airway and gave him supplemental life-threatening conditions and timely It was partly because of those expe- oxygen. Two hours later he regained access to the right care. “We talk a lot riences and a perception that this crucial consciousness.” about effectiveness and quality,” says area was being ignored that Kalanzi Around the world, acutely ill and Reynolds, “but we neglect timeliness committed himself to reforming his injured people die every day because as a critical component of both. Many country’s emergency care system. they lack access to effective, timely ‘proven’ interventions only save lives Ugandan health workers are now prehospital and emergency care. Many if given in time in the right situation.” starting to acquire the skills they need as the result of a low-cost implementation of the WHO emergency care toolkit led by the Ministry of Health (MOH) and supported by WHO and the African Federation for Emergency Medicine, with coordination by Kalanzi. The initiative began in 2016 with an assessment of Uganda’s emergency care capacity, using WHO’s Emergency Care System Assessment tool, which helps identify system gaps, and brings together a wide range of stakeholders to come to an agreement on priority actions. After a meeting convened in Kam- pala in July 2016, the actions identified included the training and equipping of frontline prehospital and hospital Sean Kivlehan/Courtesy of WHO. Sean Kivlehan/Courtesy of providers, increasing the coverage and quality of ambulance services and im- Staff at the Kawolo District Hospital in Lugazi, Uganda learn how to roll a trauma patient as part of their Basic proving processes in hospital emergency emergency care training. units. The focus was on the provision 314 Bull World Health Organ 2019;97:314–315 | doi: http://dx.doi.org/10.2471/BLT.19.020519 News of emergency care training for hospital Mirembe, who along with Halimah conditions, ranging from road traffic staff, creating dedicated resuscitation ar- Adam, headed up the initiative at the injury deaths to deaths from pneumonia eas and basic emergency unit protocols. Mubende Hospital. and diarrhoea in children.” “An intervention was designed “What the nurses achieved with the based on four WHO tools,” explains resources they had was extraordinary,” Reynolds, “our Basic Emergency Care Emergency care says John-Baptiste Waniaye, Uganda’s course, two checklist protocols, a tri- Commissioner of Emergency Medical has been neglected age protocol, and resuscitation area “ Services in the Ministry of Health, and guidance.” in health system a major supporter of the emergency The intervention was rolled out in strengthening. It’s a service reform initiative. several hospitals, two of which were real blind spot. With the support of the health monitored to assess its impact. The first Teri Reynolds. ministry, the initiative has now been was Kawolo General Hospital, a 106- ” integrated into country-wide reform of bed hospital in the town of Lugazi in the health sector. “The initial plan was the Central Region of Uganda, which With no new input of resources, the to roll out the initiative in five regional handles a significant number of road nurses, supported by their colleagues, hospitals, but a recent commitment of traffic injuries that occur on the Kam- adapted the WHO guidance to their set- funds as part of the new WHO Global pala-Jinja Highway. The second was the tings in several creative ways, including Emergency and Trauma Care Initia- above-mentioned Mubende Hospital, a organizing emergency unit beds by tri- tive, supported by the Swiss-based AO 175-bed regional referral hospital. age colour category, and using the course Foundation, will make it possible to roll Both hospitals had already been content to create protocol posters and it out in all 17 regional hospitals this gathering baseline data on emergency checklists for equipment and supplies. year,” Waniaye says. care outcomes for a year as part of the They also broke down the modules of The collaboration of a newly es- MOH assessment, and two nurses and a the Basic Emergency Care (BEC) course tablished cadre of Emergency Medical clinical officer had been identified who into daily in-service education sessions Officers under Waniaye and Kalanzi’s were willing to put in the effort required and created a “BEC” rapid response leadership. As part of this reform, emer- to make the necessary changes. team, so that the newly-trained provid- gency care trainings based on the WHO The initial training of health work- ers could be called to assist anywhere tools used in this pilot will be integrated ers who were eventually to train others in the hospital. Finally, they used the into the national training curriculum took place in the capital, Kampala, principles of organizing emergency unit for health workers, including nurses, but it became clear that better results resuscitation rooms to set up “emer- doctors and students. would be achieved by doing the training gency corners” in key inpatient wards. Kalanzi celebrates these develop- on-site. “The training in Kampala was The results were remarkable. “In ments and is keen to emphasize the very useful, but it took us away from the first year of the intervention they importance of the health workers who the hospital where we are needed, and roughly halved in-hospital mortality made his vision reality. “The develop- where conditions are not the same as related to emergency conditions,” says ment of systems in which there are no in Kampala anyway,” said nurse Violet Reynolds. “The impact was seen across dedicated streams of funding falls on the shoulders of champions,” he says. “So, we need to do everything to nurture and support them, as well as documenting their efforts in a way that can be learned from and modelled.” WHO launched the Global Emer- gency and Trauma Care Initiative in December 2018 to support capacity development for the provision of quality emergency care in countries around the world, and to foster awareness through a global advocacy campaign. Reynolds welcomes the increased attention and is encouraged by the fact that Member States requested a resolution on emergency care be tabled at the upcoming World Health Assembly. “Our Member States know better than anyone what is needed,” Vijay Kannan/Courtesy of WHO Kannan/Courtesy Vijay of she says. “Their call to action in a high-level forum like the Assembly ■ Nurses in the emergency room at Lubaga Hospital, Uganda, install an intravenous line. will have enormous impact.” Bull World Health Organ 2019;97:314–315| doi: http://dx.doi.org/10.2471/BLT.19.020519 315.

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