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Background: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours.Objective: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs.Methods: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy.Results: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED “off hours” (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during “off hours” were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during “off hours” (OR 0.56, 95% CI 0.35 - 0.91).Conclusion: In U.S. EDs, ultrasound use was lower during “off hours,” even among patient populations where its use would be strongly indicated. [West J Emerg Med. 2011;12(1):90-95.]

Problem The fragmented health sector in Somalia, burdened by financial challenges and an inadequate regulatory system, struggles to provide equitable essential health services to the entire population. Approach To revise an essential package of health services that stakeholders could support and that aligned with stakeholders' financial and technical resources, the federal health ministry invited all key stakeholders in 2020 to participate in the revision process of the essential package. The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package. The note also contained a timeline and the expected contribution of each stakeholder. Stakeholders nominated representatives based on their technical expertise and knowledge of the health sector in Somalia. Local setting The health sector in Somalia involves multiple stakeholders, including the health ministry and many development partners. The private sector plays a substantial role in health-care provision. Public spending is an estimated 17% of the total health expenditure. Relevant changes After an 18-month revision process, the health ministry and development partners agreed to prioritize high-impact, cost-effective services and use a progressive realization of the package to improve access and coverage. The implementation strategy considers the health system and operational capacity of service providers, particularly in security-compromised areas. Lessons learnt The approach showed that inclusivity, collaboration and transparency were of importance for a successful revision of the package. These achievements in consensus-building and priority alignment advance the government's pursuit of equitable and comprehensive health care for all. Probleme Le secteur fragmente de la sante en Somalie, accable par des problemes financiers et un systeme reglementaire inadapte, peine a fournir des services de sante essentiels et equitables a l'ensemble de la population. Approche Afin de reviser un programme essentiel de services de sante que les parties prenantes pourraient soutenir et qui correspondrait aux ressources financieres et techniques de ces parties prenantes, le ministere federal somalien de la Sante a invite en 2020 toutes les parties prenantes cles a participer au processus de revision de ce programme essentiel. Il a distribue aux parties prenantes invitees une note de synthese decrivant la portee et l'objectif du processus de revision du programme essentiel de services. Cette note contenait egalement un calendrier et la contribution attendue de chaque partie prenante. Les parties prenantes ont designe leurs representants selon leur expertise technique et leur connaissance du secteur de la sante en Somalie. Environnement local Le secteur somalien de la sante reunit de multiples parties prenantes, y compris le ministere consacre et de nombreux partenaires de developpement. Le secteur prive joue un role important dans la fourniture de soins de sante. Les depenses publiques sont estimees a 17% des depenses totales de sante. Changements significatifs Apres un processus de revision de 18 mois, le ministere de la Sante et les partenaires de developpement sont convenus d'accorder la priorite aux services a fort impact et rentables et d'appliquer une realisation progressive du programme afin d'ameliorer l'acces aux soins de sante et leur couverture. La strategie de mise en reuvre tient compte du systeme de sante et de la capacite operationnelle des prestataires, en particulier dans les zones ou la securite est compromise. Lecons tirees Cette approche a mis en evidence que l'inclusivite, la collaboration et la transparence etaient essentielles a une revision reussie de l'ensemble du programme. Ces resultats en matiere de concertation et d'harmonisation des priorites font progresser le gouvernement dans sa quete de soins de sante equitables et complets pour tous. Situacion El sector sanitario fragmentado de Somalia, sobrecargado por problemas financieros y un sistema normativo inadecuado, tiene dificultades para prestar servicios sanitarios esenciales equitativos a toda la poblacion. Enfoque Para revisar un paquete esencial de servicios sanitarios que las partes interesadas pudieran apoyar y que se ajustara a los recursos financieros y tecnicos de las partes interesadas, el Ministerio de Sanidad federal invito a todas las partes interesadas principales en 2020 a participar en el proceso de revision del paquete esencial. El ministerio distribuyo una nota conceptual a las partes interesadas invitadas, en la que se describia el alcance y la finalidad del proceso de revision del paquete esencial. La nota tambien incluia un calendario y la contribucion esperada de cada parte interesada. Las partes interesadas designaron a sus representantes en funcion de su experiencia tecnica y su conocimiento del sector sanitario en Somalia. Marco regional Existen varias partes interesadas en el sector sanitario de Somalia, entre ellas el Ministerio de Sanidad y diversos socios para el desarrollo. El sector privado desempena una funcion importante en la prestacion de asistencia sanitaria. Se calcula que el gasto publico representa el 17% del gasto sanitario total. Cambios importantes Tras un proceso de revision de 18 meses, el Ministerio de Sanidad y los socios para el desarrollo acordaron dar prioridad a los servicios de alto impacto y rentables, y emplear una realizacion progresiva del paquete para mejorar el acceso y la cobertura. La estrategia de ejecucion tiene en cuenta el sistema sanitario y la capacidad operativa de los proveedores de servicios, sobre todo en regiones con problemas de seguridad. Lecciones aprendidas El enfoque demostro que la inclusion, la colaboracion y la transparencia eran importantes para el exito de la revision del paquete. Estos logros en materia de creacion de consenso y alineacion de prioridades hacen avanzar al Gobierno en su empeno por lograr una asistencia sanitaria equitativa e integral para todos. [phrase omitted], Introduction A prolonged period of conflict in Somalia has led to a fragile health system in the country and persisting challenges in delivering health-care services. For example, the country's universal [...]

BackgroundIndicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.Methods and findingsThe Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.ConclusionsTo track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

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.

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.

BackgroundIn 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.MethodsThis 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.ResultsDuring 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.ConclusionsIn 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.

OBJECTIVE: Translation of evidence to practice is a public health priority. Worldwide, injury is a leading cause of morbidity and mortality. Case study publications are common and provide potentially reproducible examples of successful interventions in healthcare from the patient to systems level. However, data on how well case study publications are utilized are limited. To our knowledge, the World Health Organization (WHO) published the only collection of international case studies on injury care at the policy level. We aimed to determine the degree to which these injury care case studies have been translated to practice and to identify opportunities for enhancement of the evidence-to-practice pathway for injury care case studies overall. METHODS: We conducted a systematic review across 19 databases by searching for the title, Strengthening care for the injured: Success stories and lessons learned from around the world. Data synthesis included realist narrative methods and two authors independently reviewed articles for injury topics, reference details, and extent of utilization. FINDINGS: Forty-seven publications referenced the compilation of case studies, 20 of which included further descriptions of one or more of the specific cases and underwent narrative review. The most common category utilized was hospital-based care (15 publications), with the example of Thailands quality improvement (QI) programme (10 publications) being the most commonly cited case. Also frequently cited were case studies on prehospital care (10 publications). There was infrequent utilization of case studies on rehabilitation (3 publications) and trauma systems (2 publications). No reference described a case translated to a new scenario. CONCLUSIONS: The only available collection of policy-level injury care case studies has been utilized to a moderate extent however we found no evidence of case study translation to a new circumstance. QI programs seem especially amenable for knowledge-sharing through case studies. Prehospital care also showed promise. Greater emphasis on rehabilitation and health policy related to trauma systems is warranted. There is also a need for greater methodologic rigor in evaluation of the use of case study collections in general.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

BackgroundPediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study's objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania.MethodsProspective descriptive study of children (28 days to 14 years) with sepsis [suspected infection with ≥2 clinical systemic inflammatory response syndrome (SIRS) criteria] presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested.ResultsOf the 2,232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (n = 145) of subjects. In-hospital and EMD mortality were 14.2 and 1.5%, respectively, median time to death was 3 days (IQR 1-6), and median length of stay was 6 days (IQR 1-12). SIRS criteria, the AVPU score, and the LODS had low positive (17-27.1, 33.3-43.9, 18.3-55.6%, respectively) and high negative predictive values (88.6-89.8, 86.5-91.2, 86.8-90.5%, respectively) for in-hospital mortality.ConclusionThis pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.

ObjectiveTo estimate the global and national burden of emergency conditions, and compare them to emergency care usage rates.MethodsWe coded all 291 Global Burden of Disease 2010 conditions into three categories to estimate emergency burden: conditions that, if not addressed within hours to days of onset, commonly lead to serious disability or death; conditions with common acute decompensations that lead to serious disability or death; and non-emergencies. Emergency care usage rates were obtained from a systematic literature review on emergency care facilities in low-income and middle-income countries (LMICs), supplemented by national health system reports.FindingsAll 15 leading causes of death and disability-adjusted life years (DALYs) globally were conditions with potential emergent manifestations. We identified 41 facility-based reports in 23 countries, 12 of which were in LMICs; data for 17 additional countries were obtained from national or regional reports on emergency usage. Burden of emergency conditions was the highest in low-income countries, with median DALYs of 47 728 per 100 000 population (IQR 45 253-50 085) in low-income, 25 186 (IQR 21 982-40 480) in middle-income and 15 691 (IQR 14 649-16 382) in high-income countries. Patterns were similar using deaths to measure burden and excluding acute decompensations from the definition of emergency conditions. Conversely, emergency usage rates were the lowest in low-income countries, with median 8 visits per 1000 population (IQR 6-10), 78 (IQR 25-197) in middle-income and 264 (IQR 177-341) in high-income countries.ConclusionsDespite higher burden of emergency conditions, emergency usage rates are substantially lower in LMICs, likely due to limited access to emergency care.

IntroductionThere is little research on emergency care delivery in low- and middle-income countries (LMICs). To facilitate future research, we aimed to assess the set of key metrics currently used by researchers in these settings and to propose a set of standard metrics to facilitate future research.MethodsSystematic literature review of 43,109 published reports on general emergency care from 139 LMICs. Studies describing care for subsets of emergency conditions, subsets of populations, and data aggregated across multiple facilities were excluded. All facility- and patient-level statistics reported in these studies were recorded and the most commonly used metrics were identified.ResultsWe identified 195 studies on emergency care delivery in LMICs. There was little uniformity in either patient- or facility-level metrics reported. Patient demographics were inconsistently reported: only 33% noted average age and 63% the gender breakdown. The upper age boundary used for paediatric data varied widely, from 5 to 20 years of age. Emergency centre capacity was reported using a variety of metrics including annual patient volume (n = 175, 90%); bed count (n = 60, 31%), number of rooms (n = 48, 25%); frequently none of these metrics were reported (n = 16, 8%). Many characteristics essential to describe capabilities and performance of emergency care were not reported, including use and type of triage; level of provider training; admission rate; time to evaluation; and length of EC stay.ConclusionWe found considerable heterogeneity in reporting practices for studies of emergency care in LMICs. Standardised metrics could facilitate future analysis and interpretation of such studies, and expand the ability to generalise and compare findings across emergency care settings.

Objective To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. Methods Following the PRISMA guidelines, we systematically searched PubMed[R], Scopus, EMBASE[R], Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low-and middle- income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. Results Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. Conclusion We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low-and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research. [phrase omitted] [phrase omitted] Objectif Revoir systematiquement et evaluer la qualite des analyses de rentabilite des interventions d'urgence dans les pays a faible et moyen revenu. Methodes Conformement aux lignes directrices de la methode PRISMA, nous avons effectue une recherche systematique des etudes publiees avant mai 2019 sur PubMed[R], Scopus, EMBASE[R], Cochrane Library et Web of Science. Les criteres d'inclusion etaient les suivants : (i) analyse de rentabilite originale des interventions ou ensembles d'interventions d'urgence, et (ii) analyse menee dans des pays a faible et moyen revenu. Pour identifier d'autres recherches primaires, nous avons egalement depouille les listes de reference des etudes incluses. Enfin, nous avons applique la grille CHEERS (Consolidated Health Economic Evaluation Reporting Standards) pour evaluer la qualite des etudes prises en compte. Resultats Sur les 1674 articles identifies, 35 articles correspondaient aux criteres d'inclusion. Nous avons egalement repere quatre etudes supplementaires dans les listes de reference. En revanche, nous avons exclu de nombreuses etudes car elles ne tenaient compte que des evaluations de couts sans effectuer d'analyse de rentabilite. La plupart des etudes retenues etaient des analyses portant sur une seule intervention. Les interventions d'urgence examinees par ces etudes comprenaient les services prehospitaliers, la formation des prestataires, les programmes de traitement, les etablissements et outils diagnostiques d'urgence, ainsi que le continuum de soins. La qualite des rapports figurant dans ces etudes etait variable. Conclusion Nous avons trouve de vastes lacunes dans les indications relatives a la rentabilite des interventions d'urgence dans les pays a faible et moyen revenu. Etant donne la large gamme d'interventions pratiquees actuellement, nombre d'entre elles ne font encore l'objet d'aucune evaluation. Lors de futures recherches, il pourrait donc s'averer necessaire d'aider a la prise des decisions liees a l'attribution des ressources. Ces futures recherches devront etre orientees en priorite vers les ensembles constitues de multiples interventions ainsi que vers les changements systemiques. [phrase omitted] Objetivo Revisar y evaluar sistematicamente la calidad de los analisis de rentabilidad de las intervenciones de atencion de emergencia en los paises de ingresos bajos y medios. Metodos Siguiendo las directrices de PRISMA, se realizaron busquedas sistematicas en PubMed[R], Scopus, EMBASE[R], Cochrane Library y Web of Science sobre los estudios publicados antes de mayo de 2019. Los criterios de inclusion fueron: (i) un analisis original de rentabilidad de la intervencion de atencion de emergencia o del paquete de intervenciones, y (ii) el analisis se llevo a cabo en un lugar de ingresos bajos y medios. Para identificar estudios primarios adicionales, se realizaron busquedas manuales en las listas de referencias de los estudios incluidos. Se utilizo la directriz de las Normas consolidadas de los informes de la evaluacion economica de la salud (Consolidated Health Economic Evaluation Reporting Standards) para evaluar la calidad de los estudios incluidos. Resultados De los 1674 articulos que se identificaron, 35 articulos cumplian los criterios de inclusion. Se identificaron cuatro estudios adicionales de las listas de referencia. Se excluyeron muchos estudios por considerarse evaluaciones de costos sin un analisis de efectividad. La mayoria de los estudios incluidos eran analisis de intervencion unica. Las intervenciones de atencion de emergencia evaluadas por los estudios incluidos abarcaron servicios prehospitalarios, formacion de proveedores, intervenciones de tratamiento, herramientas de diagnostico de emergencia e instalaciones y paquetes de atencion. La calidad de la informacion de los estudios era variada. Conclusion Se encontraron grandes diferencias en las evidencias sobre la rentabilidad de las intervenciones de atencion de emergencia en lugares de ingresos bajos y medios. Dada la amplitud de las intervenciones actualmente en practica, muchas intervenciones permanecen sin evaluar, lo que sugiere la necesidad de investigaciones futuras para contribuir a las decisiones de asignacion de recursos. En particular, los paquetes de intervenciones multiples y los cambios a nivel de sistema representan un aspecto prioritario de las investigaciones futuras., Introduction Emergency care is a health systems and service delivery innovation that facilitates early recognition and life-saving interventions for time sensitive acute injuries and illnesses, where a delay of hours [...]

ObjectiveTo conduct a systematic review of emergency care in low- and middle-income countries (LMICs).MethodsWe searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards.FindingsWe identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2-5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3-8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5-6.3%). The median number of patients was 30 000 per year (IQR: 10 296-60 000), most of whom were young (median age: 35 years; IQR: 6.9-41.0) and male (median: 55.7%; IQR: 50.0-59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care.ConclusionAvailable data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

The recent decision at the World Health Organization (WHO) Executive Board (EB152/3) (1) to recommend that the World Health Assembly adopt a resolution on 'Integrated emergency, critical and operative care [...]

Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. These data gaps obscure the profound health effects of lack of emergency care access in low- and middle-income countries (LMICs). As part of the Academic Emergency Medicine consensus conference "Global Health and Emergency Care: A Research Agenda," a breakout group sought to develop a priority research agenda for data collection and management within global emergency care systems.

The chief complaint is a patient's self-reported primary reason for presenting for medical care. The clinical utility and analytical importance of recording chief complaints have been widely accepted in highly developed emergency care systems, but this practice is far from universal in global emergency care, especially in limited-resource areas. It is precisely in these settings, however, that the use of chief complaints may have particular benefit. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. Globally, much work has been done to establish local practices around chief complaint collection and use, but no standards have been established and little work has been done to identify minimum effective sets of chief complaints that may be used in limited-resource settings. As part of the Academic Emergency Medicine consensus conference, "Global Health and Emergency Care: A Research Agenda," the breakout group on data management identified the lack of research on emergency chief complaints globally-especially in low-income countries where the highest proportion of the world's population resides-as a major gap in global emergency care research. This article reviews global research on emergency chief complaints in high-income countries with developed emergency care systems and sets forth an agenda for future research on chief complaints in limited-resource settings.

Background: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours.Objective: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs.Methods: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy.Results: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED “off hours” (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during “off hours” were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during “off hours” (OR 0.56, 95% CI 0.35 - 0.91).Conclusion: In U.S. EDs, ultrasound use was lower during “off hours,” even among patient populations where its use would be strongly indicated. [West J Emerg Med. 2011;12(1):90-95.]

Injury is one of the most neglected health crises of our time, yet in 2106 it accounted for 32% more than the global number of fatalities that result from malaria, [...]

Objective To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. Methods We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines--Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality Improvement programmes--were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines' implementation. Findings We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources, that together described 140 implementation events. Implementation evidence could be found for 51 countries--14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle Income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as Incorporations into policy and 19 (14%) as educational interventions. Conclusion Although WHO's trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed. Objectif Comprendre dans quelle mesure ont ete utilisees les lignes directrices pour les soins en traumatologie, publiees par l'Organisation mondiale de la Sante (OMS) entre 2004 et 2009, et definir des priorites pour la mise en oeuvre et la diffusion futures de ces lignes directrices. Methodes Nous avons procede a une revue systematique de 19 bases de donnees, en utilisant les titres anglais des trois series de lignes directrices--Guidelines for essential trauma care, Prehospital trauma care systems et Guidelines for trauma quality improvement programmes --comme termes de recherche. Les resultats ont ete valides par une analyse de citations et une consultation d'experts. Deux auteurs ont revu de facon independante chaque occurrence d'application des lignes directrices. Resultats Nous avons releve 578 occurrences qui mettaient en evidence la diffusion des lignes directrices de l'OMS concernant les soins en traumatologie et 101 sources d'information qui decrivaient 140 cas de mise en oeuvre de ces lignes directrices. Nous avons trouve des 'elements indiquant leur mise en oeuvre dans 51 pays-14 (40%) des 35 pays a revenu faible, 15 (32%) des 47 pays a revenu intermediaire tranche inferieure, 15 (28%) des 53 pays a revenu intermediaire-tranche superieure et 7 (12%) des 59 pays a revenu eleve. Sur les 140 cas de mise en oeuvre, 63 (45%) relevaient d'evaluations des besoins, 38 (27%) d'approbdtions des parties prenantes, 20 (14%) d'integrations a des politiques et 19 (14%) d'interventions pedagogiques. Conclusion Bien que les lignes directrices de l'OMS concernant les soins en traumatologie aient ete appliquees dans une large mesure, aucun element n'a permis de montrer leur mise en oeuvre dans 143 pays. Il est necessaire de realiser davantage d'evaluations des besoins en serie pour le suivi continu des capacites en matiere de soins en traumatologie dans les systemes de sante et d'integrer davantage ces lignes directrices dans l'education formelle des professionnels de sante ainsi que dans les politiques de sante. Objetivo Comprender hasta que punto se han utilizado las directrices sobre la atencion de traumatismos publicadas por la Organizacion Mundial de la Salud (OMS) entre 2004 y 2009 e identificar las prioridades para la futura implementacion y difusion de dichas directrices. Metodos Se llevo a cabo una revision sistematica, de 19 bases de datos, en la que se utilizaron como terminos de busqueda los titulos de tres conjuntos de directrices: Guidelines for essential trauma care, Prehospital trauma care systems y Guidelines for trauma quality improvement programmes. Se validaron los resultados a traves de un analisis de citas y consultas a expertos. De forma independiente, dos autores revisaron todos los informes de la implementacion de las directrices. Resultados Se identificaron 578 informes que demostraron la difusion de las directrices sobre la atencion de traumatismos de la OMS y 101 fuentes de informacion que describian 140 casos de implementacion. Se pudieron encontrar los casos de implementacion de 51 paises: 14(40%) de los 35 paises de ingresos bajos, 15 (32%) de los 47 paises de ingresos medios, 15 (28%) de los 53 paises de ingresos medios-altos y 7 (12%) de los 59 paises de ingresos altos. De las 140 implementaciones, 63 (45%) podrian categorizarse como evaluaciones de necesidades, 38 (27%) como avales de partes interesadas, 20 (14%) como incorporaciones en la politica y 19 (14%) como intervenciones educativas. Conclusion A pesar de que las directrices sobre la atencion de traumatismos de la OMS se han implementado con cierta amplitud, no se ha demostrado su implementadon en los 143 paises. Es necesario realizar mas evaluaciones de necesidades para evaluacion continuada de la capacidad de la atencion de traumatismos en los sistemas sanitarios, asi como una mayor incorporacion de las directrices tanto en la educacion formal de los profesionales sanitarios como en las politicas sanitarias., Introduction As a result of the unsafe conditions and the relatively poor outcomes once someone is injured in low- and middle-income countries, about 90% of the global burden of injury-related [...]

Primary health care is the cornerstone of a strong health system and accelerates progress towards universal health coverage (UHC) and the sustainable development goals (SDGs). A primary healthcare approach includes [...]

A primary health-care approach to service delivery places primary care at the core of integrated health services, ensuring that systems are responsive to people's needs, values and preferences. At its [...]