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Background. Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the first-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the first-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. The outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results. We enrolled 120 (4.5%) referred polytrauma adult patients. The median age was 30 years (IQR 25–39) and the ISS was 29 (IQR 24–34). The majority (85%) were males. While the median time from injury to first-health facility was 40 minutes (IQR 33–50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314–469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed group (95% CI 0.3–5.6). Having a GCS

Background Low-and middle-income countries account for over 80% of fall-related fatalities globally. However there is little emphasis on the issue and limited high quality data to understand the burden, and to inform preventive and management strategies. We characterise the burden of fall injuries in Malawi and Tanzania. Methods This multi-centre prospective descriptive study utilized trauma registry data from 10 hospitals in Malawi and 13 hospitals in Tanzania. The study included twelve months of data in Tanzania (October 2019 to September 2020), and eighteen months of data from Malawi (September 2018 to March 2020). We describe patient demographics, the causes, location, and nature of injuries, timing of arrival to hospital, and final disposition. Regression analyses were performed to determine risk factors for serious injuries. Results There were 93,178 trauma patients in the registries of both countries, of which 44,609 (47.9%) had fall related complaints. Fall injuries accounted for 55.3% and 17.4% of all trauma cases in Malawi and Tanzania respectively. Overall the median age was 16 years (Interquartile range (IQR) 8–31 years), and 62.8% were male. Most fall injuries (69.9%) occurred at home, were unintentional (98.1%), and were due to a ground level fall (74.9%). Nearly half of patients (47.9%) arrived at a facility using public transport, with median arrival time of 10 h (IQR 8–13 h) from initial injury. Extremities (87.0%) were the most commonly injured region, followed by head and neck (4.4%). Overall 3275 (7.4%) patients had potentially serious injuries. Age > 60 years was associated with two times odds of having serious injuries than those Conclusions In these facilities in Sub-Saharan Africa, fall injuries accounted for a substantial fraction of all injuries. While most common in younger males, those aged 5–13 and over 60 years were more likely to have serious injuries. Most falls occurred at home, but serious injuries were more likely to occur at recreational and work areas. Future efforts should focus on preventive strategies to mitigate these injuries.

Introduction: Road traffic collisions (RTCs) are an important public health problem in low and middle-income countries (LMIC), where 90% of RTC deaths occur. The World Health Organization has suggested strategies to address excess mortality from RTCs including efforts to combat driving after using alcohol or drugs. Data on the impact of drug and alcohol use on RTCs is limited in many low-resource settings including Tanzania. We sought to examine the prevalence of drug and alcohol use in Tanzanian RTC drivers. Methods: This prospective, observational study was conducted in the emergency centre (EC) of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. We enrolled adult drivers presenting within 24 h of an RTC. We collected a saliva test of blood alcohol content (BAC) and a urine drug screen (UDS) and administered a validated substance use disorder screening tool, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Patients were excluded from individual analyses if they could not produce saliva or urine or answer questions. Primary outcomes were rates of positive BAC, UDS and self-reported risky alcohol and drug use patterns. Results: We screened 5264 trauma patients and enrolled 418, in whom 190 had a BAC, 364 had a UDS, and 410 had a complete ASSIST. 15 of 190 patients (7.9%) had a positive BAC, and 67/361 (18.7%) had a positive UDS for at least one drug. ASSIST scores showed 75/410 (18.3%) patients were at moderate or high risk for alcohol use disorder. Few were at risk for disordered use of other non-tobacco substances. Discussion: In our population of RTC drivers, positive BAC and UDS tests were rare but many patients were at risk for an alcohol use disorder. Ideal screening for substance use in Tanzanian trauma populations may involve a combination of objective testing and a verbal screening tool.

Background. Road traffic injuries (RTIs) pose a severe public health crisis in Sub-Saharan Africa (SSA) and specifically in Tanzania, where the mortality due to RTIs is nearly double the global rate. There is a paucity of RTI data in Tanzania to inform evidence-based interventions to reduce the incidence and improve care outcomes. A trauma registry was implemented at 13 health facilities of diverse administrative levels in Tanzania. In this study, we characterize the burden of RTIs seen at these health facilities. Methods. This was a one-year prospective descriptive study utilizing trauma registry data from 13 multilevel health facilities in Tanzania from 1 October 2019 to 30 September 2020. We provide descriptive statistics on patient demographics; location; share of injury; nature, type, and circumstances of RTI; injury severity; disposition; and outcomes. Results. Among 18,553 trauma patients seen in 13 health facilities, 7,416 (40%) had RTIs. The overall median age was 28 years (IQR 22–38 years), and 79.3% were male. Most road traffic crashes (RTC) occurred in urban settings (68.7%), involving motorcycles (68.3%). Motorcyclists (32.9%) were the most affected road users; only 37% of motorcyclists wore helmets at the time of the crash. The majority (88.2%) of patients arrived directly from the site, and 49.0% used motorized (two- or three-) wheelers to travel to the health facility. Patients were more likely to be admitted to the ward, taken to operating theatre, died at emergency unit (EU), or referred versus being discharged if they had intracranial injuries (27.8% vs. 3.7%; p < 0.0001 ), fracture of the lower leg (18.9% vs. 6.4%; p < 0.0001 ), or femur fracture (12.9% vs. 0.4%; p < 0.0001 ). Overall, 36.1% of patients were admitted, 10.6% transferred to other facilities, and mortality was 2%. Conclusions. RTCs are the main cause of trauma in this setting, affecting mostly working-age males. These RTCs result in severe injuries requiring hospital admission or referral for almost half of the victims. Motorcyclists are the most affected group, in alignment with prior studies. These findings demonstrate the burden of RTCs as a public health concern in Tanzania and the need for targeted interventions with a focus on motorcyclists.

Background Critically ill patients have life-threatening conditions requiring immediate vital organ function intervention. But, critical illness in the emergency department (ED) has not been comprehensively described in resource-limited settings. Understanding the characteristics and dynamics of critical illness can help hospitals prepare for and ensure the continuum of care for critically ill patients. This study aimed to describe the pattern and outcomes of critically ill patients at the ED of the National Hospital in Tanzania from 2019 to 2021. Methodology This hospital-records-based cohort study analyzed records of all critically ill patients who attended the ED of Muhimbili National Hospital between January 2019 and December 2021. Data extracted from the ED electronic database included clinical and demographic information, diagnoses, and outcome status at the ED. Critical illness in this study was defined as either a severe derangement of one or more vital signs measured at triage or the provision of critical care intervention. Data were analyzed using Stata 17 to examine critical illnesses' burden, characteristics, first-listed diagnosis, and outcomes at the ED. Results Among the 158,445 patients who visited the ED in the study period, 16,893 (10.7%) were critically ill. The burden of critical illness was 6,346 (10.3%) in 2019, 5,148 (10.9%) in 2020, and 5,400 (11.0%) in 2021. Respiratory (18.8%), cardiovascular (12.6%), infectious diseases (10.2%), and trauma (10.2%) were the leading causes of critical illness. Most (81.6%) of the critically ill patients presenting at the ED were admitted, of which 11% were admitted to the ICUs and 89% to general wards. Of the critically ill, 4.8% died in the ED. Conclusion More than one in ten patients attending the Tanzanian National Hospital emergency department was critically ill. The number of critically ill patients did not increase during the pandemic. The majority were admitted to general hospital wards, and about one in twenty died at the ED. This study highlights the burden of critical illness faced by hospitals and the need to ensure the availability and quality of emergency and critical care throughout hospitals.

Introduction The World Health Organization's (WHO's) Basic Emergency Care (BEC) course was developed to address training gaps in low- and middle-income countries (LMICs). Simultaneously, LMICs have experienced an unprecedented increase in the number of cell phone and internet users. We developed a mobile application adjunct to the BEC course (BEC app) and sought to assess the reach of the BEC app. Methods Forty-six BEC course participants, made up of doctors and nurses from three hospital sites in Tanzania, were given access to the BEC app with download instructions. Moderators tracked mobile access characteristics and barriers. This is a descriptive study outlining the implementation of the BEC app and associated findings from the process. Results Fewer than 10% of participants were able to independently download and use the application. The download process revealed three key barrier areas: accessibility (no smartphone, smartphone without charge, no access to data/WiFi to download app, increased cost of data), technical (outdated operating system, inconsistent access to data/WiFi to run the app, insufficient phone storage), and participant-related characteristics (variability in smartphone literary, language discordance, smartphone turnover). Of the 46 participants, 29 (63%) were able to download and use the BEC app successfully with moderator support. Conclusions There is potential utility of mobile health in LMICs. However, barriers still exist to reaching the largest possible audience for these initiatives. The importance of app compatibility with a broad range of operating systems and limitation of the amount of data needed to download and use the app was underscored by our study. Moreover, creative solutions are needed to facilitate large-scale roll-outs of mobile health interventions, such as a distribution model that relies on super user and peer support rather than an individual moderator. Additional local perspectives on the download process and the utilisation and acceptance of the application post-implementation are needed.

Background Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness. Methodology This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients. Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively. Results We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9–60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1–5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4–4.0) and 1.8(95% CI 1.1–2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9–1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021). Conclusion The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Background The survival of children who suffer cardiac arrest is poor. This study aimed to determine the predictors and outcome of cardiac arrest in paediatric patients presenting to an emergency department of a tertiary hospital in Tanzania. Methodology This was a prospective cohort study of paediatric patients > 1 month to ≤ 14 years presenting to Emergency Medicine Department of Muhimbili National Hospital (EMD) in Tanzania from September 2019 to January 2020 and triaged as Emergency and Priority. We enrolled consecutive patients during study periods where patients’ demographic and clinical presentation, emergency interventions and outcome were recorded. Logistic regression analysis was performed to identify the predictors of cardiac arrest. Results We enrolled 481 patients, 294 (61.1%) were males, and the median age was 2 years [IQR 1–5 years]. Among studied patients, 38 (7.9%) developed cardiac arrest in the EMD, of whom 84.2% were ≤ 5 years. Referred patients were over-represented among those who had an arrest (84.2%). The majority 33 (86.8%) of those who developed cardiac arrest died. Compromised circulation on primary survey (OR 5.9 (95% CI 2.1–16.6)), bradycardia for age on arrival (OR 20.0 (CI 1.6–249.3)), hyperkalemia (OR 8.2 (95% CI 1.4–47.7)), elevated lactate levels > 2 mmol/L (OR 5.2 (95% CI 1.4–19.7)), oxygen therapy requirement (OR 5.9 (95% CI 1.3–26.1)) and intubation within the EMD (OR 4.8 (95% CI 1.3–17.6)) were independent predictors of cardiac arrest. Conclusion Thirty-eight children developed cardiac arrest in the EMD, with a very high mortality. Those who arrested were more likely to present with signs of hypoxia, shock and acidosis, which suggest they were at later stage in their illness. Outcomes can be improved by strengthening the pre-referral care and providing timely critical management to prevent cardiac arrest.

BackgroundGlobally, respiratory diseases cause 10 million deaths every year. With the COVID-19 pandemic, the burden of respiratory illness increased and led to significant morbidity and mortality in both high- and low-income countries. This study assessed the burden and trend of respiratory conditions among patients presenting to the emergency department of Muhimbili National Hospital in Tanzania and compared with national COVID-19 data to determine if this knowledge may be useful for the surveillance of disease outbreaks in settings of limited specific diagnostic testing.MethodsThe study used routinely collected data from the electronic information system in the Emergency Medical Department (EMD) of Muhimbili National Hospital in Tanzania. All patients presenting to the EMD in a 2-year period, 2020 and 2021 with respiratory conditions were included. Descriptive statistics and graphical visualizations were used to describe the burden of respiratory conditions and the trends over time and to compare to national Tanzanian COVID-19 data during the same period.ResultsOne in every four patients who presented to the EMD of the Muhimbili National Hospital had a respiratory condition – 1039 patients per month. Of the 24,942 patients, 52% were males, and the median age (IQR) was 34.7 (21.7, 53.7) years. The most common respiratory diagnoses were pneumonia (52%), upper respiratory tract infections (31%), asthma (4.8%) and suspected COVID-19 (2.5%). There were four peaks of respiratory conditions coinciding with the four waves in the national COVID-19 data.ConclusionsThere is a high burden of respiratory conditions among patients presenting to the EMD of Muhimbili National Hospital. The trend shows four peaks of respiratory conditions in 2020-2021 seen to coincide with the four waves in the national COVID-19 data. Real-time hospital-based surveillance tools may be useful for early detection of respiratory disease outbreaks and other public health emergencies in settings with limited diagnostic testing.

IntroductionHigh-income country (HIC) authors are disproportionately represented in authorship bylines compared with those affiliated with low and middle-income countries (LMICs) in global health research. An assessment of authorship representation in the global emergency medicine (GEM) literature is lacking but may inform equitable academic collaborations in this relatively new field.MethodsWe conducted a bibliometric analysis of original research articles reporting studies conducted in LMICs from the annual GEM Literature Review from 2016 to 2020. Data extracted included study topic, journal, study country(s) and region, country income classification, author order, country(s) of authors’ affiliations and funding sources. We compared the proportion of authors affiliated with each income bracket using Χ2 analysis. We conducted logistic regression to identify factors associated with first or last authorship affiliated with the study country.ResultsThere were 14 113 authors in 1751 articles. Nearly half (45.5%) of the articles reported work conducted in lower middle-income countries (MICs), 23.6% in upper MICs, 22.5% in low-income countries (LICs). Authors affiliated with HICs were most represented (40.7%); 26.4% were affiliated with lower MICs, 17.4% with upper MICs, 10.3% with LICs and 5.1% with mixed affiliations. Among single-country studies, those without any local authors (8.7%) were most common among those conducted in LICs (14.4%). Only 31.0% of first authors and 21.3% of last authors were affiliated with LIC study countries. Studies in upper MICs (adjusted OR (aOR) 3.6, 95% CI 2.46 to 5.26) and those funded by the study country (aOR 2.94, 95% CI 2.05 to 4.20) had greater odds of having a local first author.ConclusionsThere were significant disparities in authorship representation. Authors affiliated with HICs more commonly occupied the most prominent authorship positions. Recognising and addressing power imbalances in international, collaborative emergency medicine (EM) research is warranted. Innovative methods are needed to increase funding opportunities and other support for EM researchers in LMICs, particularly in LICs.

Background Trauma contributes significantly to the burden of disease and mortality in sub-Saharan Africa (SSA). Like most of SSA, Tanzania lacks prospective trauma registries (TRs), resulting in poor and inconsistent availability of injury data. A model TR was implemented at five representative regional hospitals in Tanzania; the TR incorporates the variables recommended by the World Health Organisation (WHO) Data Set for Injury. This study characterises the burden of trauma seen at five regional hospital Emergency Units (EUs) in Tanzania using data from this new TR. Methods This prospective descriptive study used TR data from EUs of five regional Hospitals in Tanzania between February 2019 to September 2019. Descriptive statistics were calculated for mechanism of injury, injury severity, disposition and mortality. Injury severity scores were calculated. We determined relative risk for mortality by injury type. Results Over a seven-month period, 6,302 (9.6%) patients presented to these EUs with trauma-related complaints. They had a median age of 27 (IQR: 19–37) years and 71.3% were male. Most patients (76.6%) were self-referred and presented to EU on motorized (two or three-wheeler) vehicle (55.9%). Road traffic accidents (RTAs) 3786 (60.3%) were the most common mechanism of injury. Most patients (63.3%) presented with injuries to the upper and lower extremities, while few (2.0%) had injuries to the chest. The overall mean Injury Severity Score (ISS) was 9 (Interquartile Range (IQR): 4–13], and varied by hospital. Total 24-hour mortality was 3.3% and 126 (2.1%) patients died while receiving care at the EU. Among those who died, 156 (81.7%) had an intracranial injury; relative risk of death was [13.3 (CI95%: 9.3 -19.1), p Conclusions TR from these five Tanzanian regional hospitals has provided an opportunity to more accurately describe the country's burden of injury. Having sufficient data for ISS and other key trauma variables allows us to compare the burden and outcomes of trauma in Tanzania with other countries, which will help to quantify an accurate burden of injury, inform quality improvement initiatives, and suggest where to focus preventative measures.

Background Appropriate referrals of injured patients could improve clinical outcomes and management of healthcare resources. To gain insights for system development, we interrogated the current situation by assessing burden, patient demography, causes of injury, trauma mortality and the care-process. Methods We used an observational, cross-sectional study design and convenience sampling to review patient charts from 3 major hospitals and the death registry in Tanzania. Results Injury constitutes 9–13% of the Emergency Centre census. Inpatient trauma-deaths were 8%; however, the trauma death registry figures exceeded the ‘inpatient deaths’ and recorded up to 16%. Most patients arrive through a hospital referral system (82%) and use a hospital transport network (76%). Only 8% of the trauma admissions possessed National Health Insurance. Road traffic collision (RTC) (69%), assault (20%) and falls (9%) were the leading causes of injury. The care process revealed a normal primary-survey rate of 73–90%. Deficiencies in recording were in the assessment of: Airway and breathing (67%), circulation (40%) and disability (80%). Most patients had non-operative management (42–57%) or surgery for wound care or skeletal injuries (43%). Laparotomies were performed in 26%, while craniotomy and chest drain-insertion were each performed in 10%. Conclusion The burden of trauma is high, and the leading causes are: RTC, assault, and falls. Deaths recorded in the death registries outweigh in-hospital deaths for up to twofold. There are challenges in the care process, funding and recording. We found a functional hospital referral-network, transport system, and death registry.

Background Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania. Methods This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality. Results Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35–60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001). Conclusion Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Background: Over 40% of the global burden of sepsis occurs in children under 5 years of age, making pediatric sepsis the top cause of death for this age group. Prior studies have shown that outcomes in children with sepsis improve by minimizing the time between symptom onset and treatment. This is a challenge in resource-limited settings where access to definitive care is limited.Methods: A secondary analysis was performed on data from 1,803 patients (28 days−14 years old) who presented to the emergency department (ED) at Muhimbili National Hospital (MNH) from July 1, 2016 to June 30, 2017 with a suspected infection and ≥2 clinical systemic inflammatory response syndrome criteria. The objective of this study was to determine the relationship between delayed presentation to definitive care (>48 h between fever onset and presentation to the ED) and mortality, as well as the association between socioeconomic status (SES) and delayed presentation. Multivariable logistic regression models tested the two relationships of interest. We report both unadjusted and adjusted odds ratios and 95% confidence intervals.Results: During the study period, 11.3% (n = 203) of children who presented to MNH with sepsis died inhospital. Delayed presentation was more common in non-survivors (n = 90/151, 60%) compared to survivors (n = 614/1,353, 45%) (p ≤ 0.01). Children who had delayed presentation to definitive care, compared to those who did not, had an adjusted odds ratio for mortality of 1.85 (95% CI: 1.17–3.00).Conclusions: Delayed presentation was an independent risk factor for mortality in this cohort, emphasizing the importance of timely presentation to care for pediatric sepsis patients. Potential interventions include more efficient referral networks and emergency transportation systems to MNH. Additional clinics or hospitals with pediatric critical care may reduce pediatric sepsis mortality in Tanzania, as well as parental education programs for recognizing pediatric sepsis.

All too frequent, valuable research output and scholarly materials from expensively conducted research work in different parts of the world end up in research desks, academic libraries, and scientific journals. Muhimbili University of Health and Allied Science (MUHAS) through the Directorate of Research and Publications initiated a series of symposia that aim to disseminate the evidence generated by the researchers to the policy makers and the community. In two of the six conducted University-wide symposia in the last one year, MUHAS produced two important policy briefs summarizing the impact of MUHAS research in two important—though distinct areas of local and global health impact—Elimination of Mother to Child Transmission (EMTCT) of HIV, and Diarrhea diseases.

Background. Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. Methods. MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. Results. We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. Conclusion. We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.

Introduction: The World Health Organization recently recognized the importance of emergency and trauma care in reducing morbidity and mortality. Training programs are essential to improving emergency care in low-resource settings; however, a paucity of comprehensive curricula focusing specifically on pediatric emergency medicine (PEM) currently exists. The African Federation for Emergency Medicine (AFEM) developed a PEM curriculum that was pilot-tested in a non-randomized, controlled study to evaluate its effectiveness in nurses working in a public Tanzanian referral hospital. Methods: Fifteen nurses were recruited to participate in a two-and-a-half-day curriculum of lectures, skill sessions, and simulation scenarios covering nine topics; they were matched with controls. Both groups completed pre- and post-training assessments of their knowledge (multiple-choice test), self-efficacy (Likert surveys), and behavior. Changes in behavior were assessed using a binary checklist of critical actions during observations of live pediatric resuscitations. Results: Participant-rated pre-training self-efficacy and knowledge test scores were similar in both control and intervention groups. However, post-training, self-efficacy ratings in the intervention group increased by a median of 11.5 points (interquartile range [IQR]: 6-16) while unchanged in the control group. Knowledge test scores also increased by a median of three points (IQR: 0-4) in the nurses who received the training while the control group’s results did not differ in the two periods. A total of 1192 pediatric resuscitation cases were observed post-training, with the intervention group demonstrating higher rates of performance of three of 27 critical actions. Conclusion: This pilot study of the AFEM PEM curriculum for nurses has shown it to be an effective tool in knowledge acquisition and improved self-efficacy of pediatric emergencies. Further evaluation will be needed to assess whether it is currently effective in changing nurse behavior and patient outcomes or whether curricular modifications are needed.

Background Non-traumatic chest pain (NTCP) is a common reason for emergency department (ED) attendance in high-income countries, with the primary concern focused on life threatening cardiovascular diseases. There is general lack of data on aetiologies, diagnosis and management of NTPC in Sub Sahara African (SSA) countries. We aimed to describe evaluation, diagnosis and outcomes of adult patients presenting with NTCP to an urban ED in Tanzania. Method This was a prospective observational cohort study of consecutive adult (≥18 years) patients presenting with non-traumatic chest pain to the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) in Dar es salaam from September 2017 to April 2018. Structured case report form was used to collected demographics, clinical presentation, investigations, diagnosis, and EMD disposition and in hospital mortality. We determined frequency of NTCP among our patients, aetiologies, 24-h and 7-day in-hospital mortality, and predictors for mortality. Results We screened 29,495 adults attending EMD-MNH during the study and 389 (1.3%) presented with NTCP of these, 349 (90%) were enrolled. The median age was 45 (IQR 29–60) years and 177 (50.7%) were female. Overall, 69.1% patients received electrocardiography (ECG) in the EMD and 34.1% had a troponin test. Heart failure and pulmonary tuberculosis (PTB) were the leading hospital diagnoses (12.6% each), followed by chronic kidney disease (10%) and acute coronary syndrome (ACS) (9.6%). Total of 167 (48%) patients were admitted, and the 24-h and 7-day in-hospital mortality were 5 (3%) and 16 (9.6%) respectively. Univariate risk factors for mortality were a Glasgow Coma Scale of 0.04 ng/ml [RR 2.9 (95%CI 1.2–7.3)]. Features distinguishing cardiovascular from other causes were: bradycardia [RR = 2.6 (95%CI 2.1–3.2)], heart beat awareness [RR = 2.3 (95%CI 1.7–3.2)] and history of diabetic mellitus [RR = 2.2 (95% CI 1.6–3.0)]. Conclusion In this ED of SSA country, heart failure and pulmonary tuberculosis were the leading causes of NCTP, and ACS was present in 9.6%. NTCP in this setting carries high mortality, and ACS was the leading risk factor for death. ED providers in SSA must increasingly consider cardiovascular causes of NTCP.

BackgroundDue the high prevalence of Human Immune Virus (HIV), provider-initiated HIV testing for patients attending any health care setting is recommended. However, follow-up and linkage to care by those tested remains poor. We determined the feasibility and efficacy of text-messaging to promote follow-up among otherwise healthy trauma patients who underwent provider-initiated HIV testing and counseling at an Emergency Department (ED) in Tanzania. Material and methodsThis randomized controlled trial was conducted at Muhimbili National Hospital (MNH) ED between September 2019 to February 2020. Adult trauma patients consenting to HIV testing and follow-up text messaging were randomized to standard care (pre and post-test counseling) or standard care plus a series of 3 text-message reminders for follow-up in an HIV clinic, if positive, or retesting, if negative. Investigators blinded to study assignment called participants 2-months after the ED visit if HIV positive, or 4 months if HIV negative. We compared the proportion of people in the intervention and control groups completing recommended follow- up. Secondary outcomes were proportion accepting testing, agreeing to receive SMS and follow-up compliance by HIV status. ResultsOf 290 patients approached, 255 (87.9%) opted-in for testing and consented to the study. The median age of the study population was 29 [IQR 24-40] years. 127 (49.8%) were randomized to the intervention group and 128 (50.2%) to the control group. The short message service (SMS) system verified that 381 text messages in total were received. We traced 242 (94.9%) participants: 124 (51.2%) from intervention group and 118 (48.8%) controls. 100 (39.2%) subjects reported attending a follow-up visit, of which 77 (60.6%) were from the intervention group and 23 (17.9%) were controls. (RR = 3.4, 95%CI (2.3-5.0) resulting in number needed to treat (NNT) of 2.3. Of 246 HIV negative participants, 37% went for repeat-screening: 59% of those in the intervention group and 16% in the control group (RR= 3.7, P =

Background Due to the high prevalence of human immunodeficiency virus (HIV) in Tanzania, provider-initiated HIV testing for patients attending any health care setting is recommended. However, follow-up and linkage to care by those tested remain poor. We determined the feasibility and efficacy of text messaging to promote follow-up among otherwise healthy trauma patients who underwent provider-initiated HIV testing and counseling at an emergency department (ED) in Tanzania. Material and methods This randomized controlled trial (RCT) was conducted at Muhimbili National Hospital (MNH) ED between September 2019 and February 2020. Adult trauma patients consenting to HIV testing and follow-up text messaging were randomized to standard care (pre-test and post-test counseling) or standard care plus a series of three short message service (SMS) text message reminders for follow-up in an HIV clinic, if positive, or for retesting, if negative. Investigators blinded to the study assignment called participants 2 months after the ED visit if HIV-positive or 4 months if HIV-negative. We compared the proportion of people in the intervention and control groups completing recommended follow-up. Secondary outcomes were the proportion of patients agreeing to testing, proportion of patients agreeing to receiving text messages, and the proportion of HIV-positive and HIV-negative patients in each study arm who followed up. Results Of the 290 patients approached, 255 (87.9%) opted-in for testing and agreed to receive a text message. The median age of the study population was 29 [IQR 24–40] years. There were 127 patients randomized to the intervention group and 128 to the control group. The automated SMS system verified that 381 text messages in total were successfully sent. We traced 242 (94.9%) participants: 124 (51.2%) in the intervention group and 18 (488%) in the control group. A total of 100 (39.2%) subjects reported completing a follow-up visit, of which 77 (60.6%) were from the intervention group and 23 (17.9%) were from the control group (RR = 3.4, 95% CI 2.3–5.0). This resulted in a number needed to treat (NNT) of 2.3. Of the 246 HIV-negative participants, 37% underwent repeat screening: 59% of those in the intervention group and 16% in the control group (RR = 3.7, P = Conclusion Automated text message is a feasible and effective way to increase follow-up in HIV-tested individuals in a limited income country.

BackgroundGlobally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and timely treatment of critically ill patients across all medical specialities. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.MethodsA Delphi process was conducted to seek consensus (>90% agreement) in a diverse panel of global clinical experts. The panel was asked to iteratively rate proposed treatments and actions based on previous guidelines and the WHO/ICRC’s Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible EECC package of clinical processes plus a list of hospital resource requirements.ResultsThe 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 hospital readiness requirements. The essential diagnosis-specific care of critically ill COVID-19 patients has an additional 7 clinical processes and 9 hospital readiness requirements.ConclusionThe study has specified the content of the essential emergency and critical care that should be provided to all critically ill patients. Implementation of EECC could be an effective strategy to reduce preventable deaths worldwide. As critically ill patients have high mortality rates, especially where trained staff or resources are limited, even small improvements would have a large impact on survival. EECC has a vital role in the effective scale-up of oxygen and other care for critically ill patients in the COVID-19 pandemic. Policy makers should prioritise EECC, increase its coverage in hospitals, and include EECC as a component of universal health coverage.

Occurrence of retained rectal foreign bodies with bowel perforation resulting from auto-eroticism is rare among males in Africa. Embarrassment attached to this condition may delay or derail acquisition of information and management. A 30-year-old male presented with abdominal pain and constipation for 3 days. Abdominal X-rays revealed free air-stripes under both hemidiaphragms and in the peripherals, a 25cm x 5.9cm lucent foreign body on the left side with proximal tapering. There was no evidence of intestinal obstruction. This was consistent with bowel perforation secondary to foreign body introduction. Exploratory laparotomy was performed, a plastic bottle of 250mls was removed from the colon. Transverse repair of a 10cm laceration extending from the rectum to the sigmoid was done and a colostomy placed. A high index of suspicion, a systematic approach and a lower threshold for imaging studies were key to successful management and favorable outcomes of this patient.

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.

Background There are several curricula developed to train providers in low-resource settings on how to care for critically ill and injured children, however few incorporate the unique needs, insights, and challenges faced by the providers. Using a mixed methods approach, we conducted a needs assessment to determine the most important learning issues, attitudes, and beliefs of emergency department (ED) providers at Muhimbili National Hospital (MNH) about the development of a novel pediatric emergency medicine (PEM) curriculum for their setting. Methods A retrospective, observational, analysis of a database of pediatric ( Results Analysis of 16005 visits showed that 8 of the top 15 most common diagnoses were shared with the 15 most important topics identified by healthcare providers from the qualitative analysis; sepsis, anemia, malnutrition, congenital heart disease, pneumonia, burns, malaria, and seizures. Twenty-one healthcare providers (2 ED attending physicians, 1 pediatric attending, 5 ED residents, 9 nurses, and 4 registrars) participated and thematic saturation was achieved. Fifty-seven percent of respondents (n=13) preferred a course taught in-person, and 58% (n=15) preferred a course length of less than six months. Respondents preferred a mixed instruction approach of lectures and didactics with simulation and skills stations. Three principal perspectives on poor patient outcomes were identified; i) delayed presentation to care from a lack of recognition of disease severity and/or inappropriate or inadequate treatment; ii) poor communication and a lack of knowledge of pediatric resuscitation and critical care, and limited pediatric supplies and equipment; and iii) inadequate inpatient care despite ED stabilization. Conclusions Emergency care providers reported interest in participating in a short PEM curriculum with both live training and self-administered learning. The topics identified were concordant between participants and a database analysis, as well as previously published studies. Themes on poor patient outcomes have provided a deeper context into which the curriculum will be taught. These findings can inform future curriculum development efforts.

Background Road traffic accidents (RTAs) have emerged as an important public health problem in low and middle-income countries, where 90% of RTA deaths occur. The World Health Organization has suggested strategies to address excess mortality from RTAs including efforts to combat driving while intoxicated. The association between substance use and RTAs is well known in high-income countries, but data is more limited in low-resource settings including Tanzania. The objective of this study is to examine the prevalence of drug use, alcohol use, and substance use disorders in Tanzanian RTA drivers. Methods This prospective observational study was conducted in the Emergency Department of Muhimbili National Hospital, a national referral hospital in Dar es Salaam, Tanzania. Research assistants available 24 hours per day enrolled adult drivers who presented within 24 hours of an RTA. In eligible patients, research assistants collected a saliva test of blood alcohol content (BAC) and a urine drug screen (UDS), and administered a validated substance abuse screening tool, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Patients were excluded from individual analyses if they could not produce a saliva or urine test or answer questions. Primary outcomes were rates of positive BAC, UDS and self-reported high-risk alcohol and drug use patterns. Descriptive statistics were calculated using Excel. Results We screened 5264 trauma patients and enrolled 538, in whom 191 had a BAC, 362 had a UDS, and 417 had a complete ASSIST. Fifteen of 191 patients (7.8%) had a positive BAC, and 68/362 (18.7%) patients had a UDS that was positive for at least one drug. Based on the ASSIST, 104/417 (24.5%) of patients were at moderate or high risk for alcohol use disorder. Few were at risk for disordered use of other non-tobacco substances. Conclusion In our population of drivers presenting within 24 hours of an RTA, positive BAC and UDS tests were rare. A substantial portion of the population was at moderate to high risk for an alcohol use disorder. Ideal screening for substance use in trauma populations may involve a verbal screening tool, particularly when the time between injury and hospital arrival is delayed.

Background Trauma registries (TRs) are essential to informing the quality of trauma care within health systems. Lack of standardised trauma documentation is a major cause of inconsistent and poor availability of trauma data in most low- and middle-income countries (LMICs), hindering the development of TRs in these regions. We explored health providers’ perceptions on the use of a standardised trauma form to record trauma patient information in Tanzania. Methods An exploratory qualitative research using a semi-structured interview guide was carried out to purposefully selected key informants comprising of healthcare providers working in Emergency Units and surgical disciplines in five regional hospitals in Tanzania. Data were analysed using a thematic analysis approach to identify key themes surrounding potential implementation of the standardised trauma form. Results Thirty-three healthcare providers participated, the majority of whom had no experience in the use of standardised charting. Only five respondents had prior experience with trauma forms. Responses fell into three themes: perspectives on the concept of a standardised trauma form, potential benefits of a trauma form, and concerns regarding successful and sustainable implementation. Conclusion Findings of this study revealed wide healthcare provider acceptance of moving towards standardised clinical documentation for trauma patients. Successful implementation likely depends on the perceived benefits of using a trauma form as a tool to guide clinical management, standardise care and standardise data reporting; however, it will be important moving forward to factor concerns brought up in this study. Potential barriers to successful and sustainable implementation of the form, including the need for training and tailoring of form to match existing resources and knowledge of providers, must be considered.

Background Emergency medicine (EM) is a new specialty in Tanzania. Little is known about how to introduce EM to health care providers (HCPs) in hospitals without EM. We determined the impact of a 2-day EM training program on the understanding, perception, and choice of EM as a career amongst HCPs at hospitals in Tanzania without EM. Methods This was a pre- and post-training interventional study including randomly selected HCPs from four tertiary hospitals in Tanzania without EM. Understanding, perception, and desirability of EM as a career were assessed before and after a 2-day university-accredited basic EM short-course training given by EM physicians. A paper-based Likert scale (out of 5) questionnaire was used, which were analyzed by T tests, Mann-Whitney, and Kruskal-Wallis tests. Results During the study period, 96 health care providers (100% capture) in the four tertiary hospitals participated in the study. The median age of participants was 34 years (IQR 28–43); 35 (36.0%) were males. Sixty (63%) were nurses, 26 (27%) doctors, and 3 (3%) were administrators. The four hospitals were equally represented. Median pre-training scores for all Likert questions were 3.49 (IQR 3.3–3.9); understanding 3.3 (IQR 3.0–3.7), perception 3.40 (IQR 3.1–3.7), and career decision-making 3.7 (IQR 3.3–4.0). Post-training scores improved with median scores of 4.6 (IQR 4.5–4.7) overall, 4.7 (IQR 4.0–4.7) for understanding, 4.6 (IQR 4.5–4.9) for perception, and 4.7 (IQR 4.3–4.8) for career decision-making (all p

Introduction: Emergency medicine (EM) throughout Africa exists in various stages of development. The number and types of scientific EM literature can serve as a proxy indicator of EM regional development and activity. The goal of this scoping review is a preliminary assessment of potential size and scope of available African EM literature published over 15 years. Methods: We searched five indexed international databases as well as non-indexed grey literature from 1999-2014 using key search terms including “Africa”, “emergency medicine”, “emergency medical services”, and “disaster.” Two trained physician reviewers independently assessed whether each article met one or more of five inclusion criteria, and discordant results were adjudicated by a senior reviewer. Articles were categorised by subject and country of origin. Publication number per country was normalised by 1,000,000 population. Results: Of 6091 identified articles, 633 (10.4%) were included. African publications increased 10-fold from 1999 to 2013 (9 to 94 articles, respectively). Western Africa had the highest number (212, 33.5%) per region. South Africa had the largest number of articles per country (171, 27.0%) followed by Nigeria, Kenya, and Ghana. 537 (84.8%) articles pertained to facility-based EM, 188 (29.7%) to out-of-hospital emergency medicine, and 109 (17.2%) to disaster medicine. Predominant content areas were epidemiology (374, 59.1%), EM systems (321, 50.7%) and clinical care (262, 41.4%). The most common study design was observational (479, 75.7%), with only 28 (4.4%) interventional studies. All-comers (382, 59.9%) and children (91, 14.1%) were the most commonly studied patient populations. Undifferentiated (313, 49.4%) and traumatic (180, 28.4%) complaints were most common. Conclusion: Our review revealed a considerable increase in the growth of African EM literature from 1999 to 2014. Overwhelmingly, articles were observational, studied all-comers, and focused on undifferentiated complaints. The articles discovered in this scoping review are reflective of the relatively immature and growing state of African EM. Keywords: Emergency medicine, EM, Emergency medical services, EMS, Africa, Scoping review, Literature review

Background Alcohol and illicit drugs have been found to be major contributing factors leading to severe injuries in a variety of settings. In Tanzania, the use of these substances among injured patients has not been studied. We investigated the prevalence of positive tests for alcohol and illicit drug use among injured patients presenting to the emergency medicine department (ED) of Muhimbili National Hospital (MNH). Methods This was a prospective cohort study of a consecutive sample of patients > 18 years of age presenting to the ED-MNH with injury related complaints in October and November 2015. A structured data sheet was used to record demographic information, mechanism of injury, clinical presentation, alcohol and illicit drug test results, and ED disposition. Alcohol levels and illicit drug use were tested by breathalyser device or swab stick alcohol test and multidrug urine panel, respectively. Patients were followed up for 24 h and 30 days using medical chart reviews and phone calls. Descriptive statistics and relative risk were used to describe the results. Results We screened 1011 patients and we enrolled all 143 (14.1%) patients who met inclusion criteria. 123 (86.0%) were male, the median age was 30 years (IQR: 23–36 years). The most frequent mechanism of injury was road traffic accidents (84.6%). 67/143 (46.9%) patients tested positive for alcohol and 44/122 (36.1%) patients tested positive for drugs. 29 (26.1%) tested positive for alcohol and drugs. The most frequently detected illicit drug was marijuana in 30/122 (24.5%) injured patients. 23/53 (43.4%) patients with positive alcohol testing self-reported alcohol use. 3/25 patients with positive illicit drug tests who were able to provide self-reports, self-reported drug use. At 30-day followup, 43 (64.2%) injured patients who tested positive for alcohol had undergone major surgery, 6 (9.0%) had died, and 36 (53.7%) had not yet returned to their baseline. Conclusions The prevalence of alcohol and illicit drugs is very high in patients presenting to the ED-MNH with injury. Further studies are needed to generalise the results in Tanzania. Public health initiatives to decrease drinking and/or illicit drug use and driving should be implemented. Electronic supplementary material The online version of this article (10.1186/s12873-019-0222-9) contains supplementary material, which is available to authorized users.

Background In Tanzania, there is no national trauma registry. The World Health Organization (WHO) has developed a data set for injury that specifies the variables necessary for documenting the burden of injury and patient-related clinical processes. As a first step in developing and implementing a national Trauma Registry, we determined how well hospitals currently capture the variables that are specified in the WHO injury set. Methods This was a prospective, observational cross-sectional study of all trauma patients conducted in the Emergency Units of five regional referral hospitals in Tanzania from February 2018 to July 2018. Research assistants observed the provision of clinical care in the EU for all patients, and documented performed assessment, clinical interventions and final disposition. Research assistants used a purposefully designed case report form to audit the injury variable capture rate, and to review Ministry of Health (MoH) issued facility Register book recording the documentation of variables. We present descriptive statistics for hospital characteristics, patient volume, facility infrastructure, and capture rate of trauma variables. Results During the study period, 2891 (9.3%) patients presented with trauma-related complaints, 70.7% were male. Overall, the capture rate of all variables was 33.6%. Documentation was most complete for demographics 71.6%, while initial clinical condition, and details of injury were documented in 20.5 and 20.8% respectively. There was no documentation for the care prior to Emergency Unit arrival in all hospitals. 1430 (49.5%) of all trauma-related visits seen were documented in the facility Health Management Information System register submitted to the MoH. Among the cases reported in the register book, the date of EU care was correctly documented in 77% cases, age 43.6%, diagnosis 66.7%, and outcome in 38.9% cases. Among the observed procedures, initial clinical condition (28.7%), interventions at Emergency Unit (52.1%), investigations (49.0%), and disposition (62.9%) were documented in the clinical charts. Conclusions In the regional hospitals of Tanzania, there is inadequate documentation of the minimum trauma variables specified in the WHO injury data set. Reasons for this are unclear, but will need to be addressed in order to improve documentation to inform a national injury registry.

BackgroundThere is a pressing need for emergency care (EC) training in low-resource settings. We assessed the feasibility and acceptability of training frontline healthcare providers in emergency care with the World Health Organization (WHO)-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) Course using a training-of-trainers (ToT) model with local providers.MethodsQuasiexperimental pretest and post-test study of an educational intervention at four first-level district hospitals in Tanzania and Uganda conducted in March and April of 2017. A 2-day ToT course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC Course, taught by the newly trained trainers, at two hospitals in each country. Both prior to and immediately following each training, participants took assessments on EC knowledge and rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants was collected and summarised.ResultsFifty-nine participants completed the four BEC Courses. All participants were current healthcare workers at the selected hospitals. An additional 10 participants completed a ToT course. EC knowledge scores were significantly higher for participants immediately following the training compared with their scores just prior to the training when assessed across all study sites (Z=6.23, pConclusionsImplementation of the WHO-ICRC BEC Course by locally trained providers was feasible, acceptable and well received at four sites in East Africa. Participation in the training course was associated with a significant increase in EC knowledge and confidence at all four study sites. The BEC is a low-cost intervention that can improve EC knowledge and skill confidence across provider cadres.

Background Proper pain assessment is a core component in management of trauma patients but prior literature has suggested that pain management is inadequate in emergency settings. With the development of emergency medicine in low-income countries (LIC), the procedures for pain assessment and management of trauma patients have not been well studied and protocols have not been established. We aimed to describe practices of pain assessment and management in an emergency department in Tanzania. Methods This was a prospective cohort study of consecutive adult trauma patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, Tanzania, from July 2017 to December 2017. A case report form (CRF) was used to record demographics and clinical characteristics of participants, whether or not pain was assessed at either triage or in the treatment area, and the administration of pain medications. The assistant also assessed pain independently with the numeric rating scale (NRS) of (0–10). Outcomes were proportions of patients who received pain assessment, patients who received pain medication, and types of medications administered. Descriptive data is summarised using frequency, percentage, and median with interquartile ranges as appropriate. Chi-square tests were used to determine association between pain assessments, receipt of pain medication, and types of medications. Results We enrolled 311 (10.9%) trauma patients during the period of study. The median age was 32 years (IQR 25–43 years), and 228 (73.3%) were male. The most common mechanism of injury was motor vehicle crash 185 (59.4%), and of these, 87 (47%) involved motorcycles. Three hundred ten (99.6%) patients had pain assessment documented arrival, and 285 (91.6%) had a second assessment. Pain scores obtained by the research assistant were as follows: mild pain score (NRS 1–3) 154 (49.5%) patients, moderate pain (NRS 4–6) 68 (21.8%), and severe pain (NRS 7–10) 89 (28.7%). Pain medications were given to 144 (46.3%) patients, 29 (20.1%) of those with mild pain, 41 (28.7%) of those with moderate pain score, and 74 (51.4%) of those with severe pain. The use of opiates increased with increased pain severity. Conclusions In this ED in LIC, the assessment of pain was well documented; however, less than half of patients with documented pain received pain medication while at the ED. Future studies should focus on identification of factors affecting the provision of pain medications to trauma patients in the ED.

Background Sickle cell anaemia (SCA) is prevalent in sub-Saharan Africa, with high risk of complications requiring emergency care. There is limited information about presentation of patients with SCA to hospitals for emergency care. We describe the clinical presentation, resource utilization, and outcomes of SCA patients presenting to the emergency department (ED) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Methods This was a prospective cohort study of consecutive patients with SCA presenting to ED between December 2014 and July 2015. Informed consent was obtained from all patients or patients’ proxies prior to being enrolled in the study. A standardized case report form was used to record study information, including demographics, relevant clinical characteristics and overall patients outcomes. Categorical variables were compared with chi-square test or Fisher’s exact test; continuous variables were compared with two-sample t-test or Mann-Whitney U-test. Results We enrolled 752 (2.7%) people with SCA from 28,322 patients who presented to the MNH-ED. The median age was 14 years (Interquartile range [IQR]: 6–23 years), and 395 (52.8%) were female. Pain 614 (81.6%), fever 289 (38.4%) were the most frequent presenting complaint. Patients with fever, hypoxia, altered mental status and bradycardia had statistically significant relative risk of mortality of 10.4, 153, 50 and 12.1 (p

Background Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. Methods This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. Results We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45–67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. Conclusion In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

Nurses are the largest group of healthcare workers in Africa. By adequately equipping nurses to identify, intervene and care for emergency conditions, emergency healthcare systems can be strengthened. To address this need, a nursing working group was formed within the African Federation for Emergency Medicine (AFEM). The aim of this international emergency nursing group was to develop a guiding document to help improve emergency nursing skills within Africa. Using this guiding document, a group of Tanzanian clinical nurse trainers was selected to develop a context specific short course. They used this guiding document as a foundation to improve skill development. The pilot course was well received and has since expanded to training in five regions within the United Republic of Tanzania. The clinical nurse trainers leading the course, are supported by a mentorship programme with competent educators within a global emergency nursing infrastructure. This course, a combination of local knowledge, formal mentorship programs, and international nursing support, demonstrates that investing in the improvement of emergency nursing skills can have high impact results with low-cost. This will ultimately improve emergency care on the continent.

Background Trauma contributes significantly to the burden of disease and mortality throughout the world, but particularly in developing countries. In Tanzania, there is an enormous research gap on trauma; the limited data available reflects realities in cities and areas with moderately- to highly-resourced treatment centers. Our aim was to provide a description of the injury epidemiology across all of Tanzania. Our data will serve as a basis for future larger studies. Methods This is a subgroup analysis of a cross-sectional, prospective study of the clinical epidemiology of patients presenting at all public district and regional hospitals in Tanzania. The study was conducted between May 2012 and December 2012. A team of emergency doctors used a purpose-designed data collection sheet to gather the demographic and clinical information of all patients presenting during the day-site visit to each hospital. Descriptive statistics, including means, standard deviations, medians, and ranges are reported. Results A total of 5227 patients were seen in 24-h period in 105 (100% response rate) district (or designated district) and regional hospitals in mainland Tanzania. Of these patients, 508 (9.7%) presented with trauma-related complaints. Among patients with trauma-related complaints, 286 (56.3%) were male, and the overall median age of 30 (interquartile range of 22–35) years. Road traffic crash was the most common mechanism of injury, accounting for 227 (44.7%) complaints. Open wounds and bone fractures were the two most frequent diagnoses, with a combined 300 (59%) cases. Most of the patients - 325 (64%) - were discharged, 11 (2.2%) went to operating theatres and 4 (0.8%) of patients died while receiving care at the acute intake areas. Conclusions Trauma-related complaints constitute a substantial burden among patients seeking care in acute intake areas of hospitals across Tanzania. There is a need to develop, implement and study systems that can support the improvement of trauma care and optimize outcomes of trauma patients.

Background Poisoning is a major public health concern in sub-Saharan Africa, affecting patients of all age groups. Poisoned patients often present to the emergency department (ED) and prompt evaluation and appropriate management are imperative to ensure optimal outcomes. Unfortunately, little is known about the specific presentations of poisoned patients in East Africa. We describe the clinical and epidemiological features of patients presenting to the Muhimbili National Hospital (MNH) ED with suspected toxicological syndromes. Methods This prospective study enrolled a consecutive sample of ED patients who presented with a suspected toxicological syndrome from March 2013 to June 2013. Trained investigators completed a structured case report form (CRF) for each eligible patient, documenting the suspected poison, demographic information, the clinical presentation, and the ED outcome and disposition. The study data were analyzed and summarized with descriptive statistics. Results Of 8827 patients, who presented to ED-MNH, 106 (1.2%) met inclusion criteria, and all were enrolled. Among those enrolled, the median age was 28 years (interquartile range [IQR] 16 years), and 81 (76.4%) were male. Overall 55 (52%) were single, and 28 (26.4%) had professional jobs. 60 (56.6%) patients were referred from district hospitals, 86.8% of which were in Dar es Salaam. Only 13 (12.3%) of patients presented to the ED within 2 h of the toxic exposure. The etiology of poisoning included alcohol in 42 (50%), a mixture of different medications in 12 (14.3%), and snakebite in 6 (11.3%). Most exposures were intentional (63 [59.4%]) and were via the oral route (88 [83%]). The most common abnormal physical findings were altered mental status (66 [62.3%]) and tachypnoea (68 [64.2%]). One patient died in the ED and 98 (92.5%) required hospital admission. Conclusions Most patients presenting to the ED with a toxicological syndrome were adult males with intentional exposures. The most common toxic exposure was alcohol (ethanol) intoxication and the most common abnormal findings were altered mental status and tachypnoea. More than three-quarter of patients presented after 2 h of exposure. Almost all patients were admitted to the hospital.

Injury is a leading cause of death globally, and organized trauma care systems have been shown to save lives. However, even though most injuries occur in low- and middle-income countries (LMICs), most trauma care research comes from high-income countries where systems have been implemented with few resource constraints. Little context-relevant guidance exists to help policy makers set priorities in LMICs, where resources are limited and where trauma care may be implemented in distinct ways. We have aimed to review the evidence on the impact of trauma care systems in LMICs through a systematic search of 11 databases. Reports were categorized by intervention and outcome type and summarized. Of 4,284 records retrieved, 71 reports from 32 countries met inclusion criteria. Training, prehospital systems, and overall system organization were the most commonly reported interventions. Quality-improvement, costing, rehabilitation, and legislation and governance were relatively neglected areas. Included reports may inform trauma care system planning in LMICs, and noted gaps may guide research and funding agendas.