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ObjectivesTo assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.DesignRetrospective cohort analysis with multivariable logistic regression.SettingSingle rural Ugandan emergency unit.ParticipantsAll patients presenting for care from 2009 to 2019.InterventionsThree cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: ‘Direct Supervision’ (2009–2010) emergency medicine physicians directly supervised all care; ‘Indirect Supervision’ (2010–2015) emergency medicine physicians were consulted as needed; ‘Independent Care’ (2015–2019) no emergency medicine physician supervision.Primary outcome measureThree-day mortality.Results38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts (‘Direct’ 3.8%, ‘Indirect’ 3.3%, ‘Independent’ 2.6%, pConclusionsEmergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.

IntroductionEmergency care (EC) capacity is limited by physician shortages in low- and middle-income countries like Uganda. Task-sharing — delegating tasks to more narrowly trained cadres — including EC nonphysician clinicians (NPCs) is a proposed solution. However, little data exists to guide emergency medicine (EM) physician supervision of NPCs. This study’s objective was to assess the mortality impact of decreasing EM physician supervision of EC NPCs.MethodsRetrospective analysis of prospectively collected data from an EC NPC training program in rural Uganda included three cohorts: “Direct” (2009-2010): EM physicians supervised all NPC care; “Indirect” (2010-2015): NPCs consulted EM physicians on an ad hoc basis; “Independent” (2015-2019): NPC care without EM physician supervision. Multivariable logistic regression analysis of three-day mortality included demographics, vital signs, co-morbidities and supervision. Sensitivity analysis stratified patients by numbers of abnormal vital signs.ResultsOverall, 38,344 ED visits met inclusion criteria. From the “Direct” to the “Unsupervised” period patients with ≥3 abnormal vitals (25.2% to 10.2%, pConclusion“Direct” EM physician supervision of NPC care significantly reduced overall mortality as the highest risk ∼10% of patients had nearly 50% reduction in mortality. However, for the other ∼90% of ED visits, independent EC NPC care had similar mortality outcomes as directly supervised care, suggesting a synergistic model could address current staffing shortages limiting EC access and quality.SUMMARY BOXWhat is already known?Physician shortages and lack of specialty training limit implementation of emergency care and associated reductions in mortality in low- and middle-income countries (LMIC) such as Uganda.Task-sharing, often to non-physician clinicians, is proposed as a solution however data to support safe, effective training and physician supervision protocols is limited.What are the new findings?The highest risk 10% of emergency care patients have approximately a 50% reduction in mortality when non-physician clinicians are directly supervised by emergency medicine physicians.For most emergency care patients (the lowest risk 90%) independent emergency care by non-physician clinicians provides similar morality outcomes to direct supervision by an emergency medicine physician.What do the new findings imply?Training of both emergency care physicians and non-physician clinicians is essential, as physicians provide improved mortality outcomes, especially for the critically ill, and non-physician clinicians will help address lack of trained and available emergency care providers in a timely, cost-effective manner.Physician supervision of all emergency care is the penultimate goal, however non-physician clinicians can be trained to provide comparable morality outcomes for the vast majority of patients when practicing independently.Triage protocols are needed to identify high-risk emergency care patients, such as those with 3 or more abnormal vital signs, for early involvement of an emergency physician either directly, or through supervision of a non-physician clinician.

Background\ud Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.\ud \ud Methods\ud In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.\ud \ud Findings\ud Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.\ud \ud Interpretation\ud Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.\ud \ud Funding\ud London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation.