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Background: Limited data exist on the outcomes of patients requiring invasive ventilation or noninvasive positive pressure ventilation (NIPPV) in low-income countries. To our knowledge, no study has investigated this topic in Haiti. Objectives: We describe the clinical epidemiology, treatment, and outcomes of patients requiring NIPPV or intubation in an emergency department (ED) in rural Haiti. Methods: This is an observational study utilizing a convenience sample of adult and pediatric patients requiring NIPPV or intubation in the ED at an academic hospital in central Haiti from January 2019-February 2021. Patients were prospectively identified at the time of clinical care. Data on demographics, clinical presentation, management, and ED disposition were extracted from patient charts using a standardized form and analyzed in SAS v9.4. The primary outcome was survival to discharge. Findings: Of 46 patients, 27 (58.7%) were female, mean age was 31 years, and 14 (30.4%) were pediatric (age <18 years). Common diagnoses were cardiogenic pulmonary edema, pneumonia/pulmonary sepsis, and severe asthma. Twenty-three (50.0%) patients were initially treated with NIPPV, with 4 requiring intubation; a total of 27 (58.7%) patients were intubated. Among those for whom intubation success was documented, first-pass success was 57.7% and overall success was 100% (one record missing data); intubation was associated with few immediate complications. Twenty-two (47.8%) patients died in the ED. Of the 24 patients who survived, 4 were discharged, 19 (intubation: 12; NIPPV: 9) were admitted to the intensive care unit or general ward, and 1 was transferred. Survival to discharge was 34.8% (intubation: 22.2%; NIPPV: 52.2%); 1 patient left against medical advice following admission. Conclusions: Patients with acute respiratory failure in this Haitian ED were successfully treated with both NIPPV and intubation. While overall survival to discharge remains relatively low, this study supports developing capacity for advanced respiratory interventions in low-resource settings.
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Ventilação não Invasiva , Adulto , Humanos , Feminino , Criança , Adolescente , Masculino , Haiti/epidemiologia , Respiração com Pressão Positiva , Unidades de Terapia Intensiva , Serviço Hospitalar de EmergênciaRESUMO
OBJECTIVE: Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings. RESULTS: Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers. CONCLUSION: These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.
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Planejamento em Desastres , Incidentes com Feridos em Massa , Planejamento em Desastres/métodos , Serviço Hospitalar de Emergência , Haiti , Humanos , Triagem/métodosRESUMO
INTRODUCTION: In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS: We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS: Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION: Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.
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Background: Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs). Objective: We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations. Methods: As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed. Findings and conclusions: ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the "front end" of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.
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Países em Desenvolvimento , Serviço Hospitalar de Emergência , Arquitetura Hospitalar , Hospitais Universitários , Haiti , Número de Leitos em Hospital , Humanos , Controle de Infecções , Monitorização Fisiológica/instrumentação , Oxigênio/provisão & distribuição , Segurança do Paciente , Privacidade , Triagem , Ventilação , Salas de EsperaRESUMO
BACKGROUND: In Haiti, like many low-income countries, traumatic injuries are leading causes of morbidity and mortality. Yet, little is known about the epidemiology of traumatic injuries in Haitian EDs. Improved understanding of injury patterns is necessary to strengthen emergency services and improve emergency provider education. METHODS: This was a retrospective cohort study of trauma patients at an academic hospital in central Haiti over 6 months. Visits were identified from the electronic medical record, and paper charts were manually reviewed. Data, including demographics, timing of presentation, injuries sustained, treatments received and ED disposition were extracted using a standardised form and later analysed in SAS V.9.3. RESULTS: Of 1401 patients, 66% were male, and the average age was 26.8 years. Most visits were due to road traffic injuries (RTIs; 48%) followed by falls (22%). Trauma mechanism varied significantly by age (p<0.001): falls predominated in children under 5 years (56%) versus RTIs for adults (59%). Only 14% of patients injured on motorcycles used helmets and 30% of those injured in motor vehicles used seatbelts. Only 18% of patients arrived within 1 hour of the trauma. Skin or soft tissue injuries were the most common (58%), followed by extremity or pelvic fractures or dislocations (23%). Most patients (81%) were discharged, 14% were admitted or stayed over 24 hours in the ED and 0.8% died in the ED. Of the admitted patients, 61% had surgery, 79% of which were orthopaedic. Patients using helmets or seatbelts were more likely to be discharged than those not using protective equipment (p=0.008). CONCLUSIONS: In this trauma population, RTIs and falls were the most common trauma mechanisms, safety feature use was rare, and most injuries were musculoskeletal. Presentation was delayed and mortality was low, but many patients required surgery. These findings have significant clinical, public health, operational and training implications.
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Ferimentos e Lesões/complicações , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Haiti/epidemiologia , Humanos , Lactente , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologiaRESUMO
BACKGROUND: In many resource-limited settings, emergency medicine (EM) is underdeveloped and formal EM training limited. Residencies and fellowships are an ideal long-term solution but cannot meet immediate needs for emergency providers, while short-term programs are often too limited in content. We describe a third method successfully implemented in Haiti: a medium-duration certificate program to meet the immediate need for emergency specialists. METHODS: In conjunction with the Haitian Ministry of Health and National Medical School, we developed and implemented a novel, 6-month EM certificate program to build human resources for health and emergency care capacity. The program consisted of didactic and supervised clinical components, covering core content in EM. Didactics included lectures, simulations, hands-on skill-sessions, and journal clubs. Supervised clinical time reinforced concepts and taught an EM approach to patient care. RESULTS: Fourteen physicians from around Haiti successfully completed the program; all improved from their pre-test to post-test. At the end of the program and 9-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily. Participants found clinical supervision and simulation particularly useful. Key components to our program's success included collaboration with the Ministry of Health and National Medical School, supervised clinical time, and the continual presence of a course director. The program could be improved by a more flexible curriculum and by grouping participants by baseline knowledge levels. CONCLUSION: Medium-duration certificate programs offer a viable option for addressing immediate human resource gaps in emergency care, and our program offers a model for implementation in resource-limited settings. Similar options should be considered for other emerging specialties in resource-limited settings.
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OBJECTIVES: The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners. METHODS: This year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. RESULTS: A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441. CONCLUSIONS: In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.
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Bibliometria , Serviços Médicos de Emergência/tendências , Medicina de Emergência/tendências , Saúde Global , Humanos , Internacionalidade , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti. METHODS: A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis. RESULTS: Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively. CONCLUSION: This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.
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Avaliação de Programas e Projetos de Saúde/métodos , Triagem/métodos , Triagem/normas , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Haiti , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Triagem/estatística & dados numéricosRESUMO
OBJECTIVES: The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners. METHODS: This year 12,435 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 723 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of overall quality and importance. Two independent reviewers scored all articles. RESULTS: A total of 723 articles met our predetermined inclusion criteria and underwent full review. Sixty percent were categorized as emergency care in resource-limited settings (ECRLS), 17% as EM development (EMD), and 23% as disaster and humanitarian response (DHR). Twenty-four articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability between reviewers gave an intraclass correlation coefficient of 0.71 (95% confidence interval = 0.66 to 0.75). Studies and reviews with a focus on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review. CONCLUSIONS: In 2015, there were almost twice as many articles found by our search compared to the 2014 review. The number of EMD articles increased, while the number ECRLS articles decreased. The number of DHR articles remained stable. As in prior years, the majority of articles focused on infectious diseases.