Abstract

Objective

To conduct a systematic review of emergency care in low- and middle-income countries (LMICs).

Methods

. We 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CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers.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.

Findings

We 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.

Conclusion

Available 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.

Resumé

Objectif

Réaliser un examen systématique des soins d'urgence dans les pays à revenu faible ou intermédiaire (PRFI).

Méthodes

Nous avons recherché dans les bases de données de PubMed, CINAHL et de l'Organisation mondiale de la Santé des rapports décrivant les soins d'urgence dispensés dans les établissements médicaux et obtenu des données non publiées auprès d'un réseau de cliniciens et de chercheurs. Nous avons sélectionné plusieurs articles à inclure d'après leur titre et leur résumé en anglais ou en français. Nous avons extrait des données liées à l'état de santé des patients, à la démographie et aux caractéristiques des établissements et des prestataires. Les analyses se sont limitées à des rapports publiés à partir de 1990.

Résultats

Nous avons identifié 195 rapports relatifs à 192 établissements implantés dans 59 pays. Il s'agissait pour la plupart d'hôpitaux universitaires situés dans des zones urbaines. La mortalité moyenne au sein des services d'urgence était de 1,8% (intervalle interquartile, IQR: 0,2-5,1%). Elle était relativement élevée dans les centres pédiatriques (moyenne: 4,8%; IQR: 2,3-8,4%) et en Afrique subsaharienne (moyenne: 3,4%; IQR: 0,5-6,3%). Le nombre moyen de patients était de 30 000 par an (IQR: 10 296-60 000), la plupart d'entre eux étant des jeunes (âge médian: 35 ans; IQR: 6,9-41,0) et de sexe masculin (moyenne: 55,7%; IQR: 50,0-59,2%). La majorité des établissements employaient des médecins en formation ou dont le niveau de formation n'était pas précisé. Rares étaient les prestataires à avoir reçu une formation spécialisée en soins d'urgence.

Conclusion

Les données existantes concernant les soins d'urgence dispensés dans les PRFI indiquent un nombre de patients et une mortalité élevés, en particulier en Afrique subsaharienne où une fraction importante de l'ensemble des décès est susceptible de survenir dans les services d'urgence. Compte tenu du nombre élevé et de l'urgence des interventions, les soins d'urgence constituent un domaine d'intérêt important pour les actions visant à réduire la mortalité dans ces lieux.

Resumen

Objetivo

Realizar una revisión sistemática de la atención de emergencia en países de ingresos medios y bajos (PIMB).

Métodos

Se realizaron búsquedas en las bases de datos de PubMed, CINAHL y la Organización Mundial de la Salud (OMS) para encontrar informes que describieran la atención de emergencia en centros sanitarios y se obtuvieron datos sin publicar de una red de clínicos e investigadores. Se seleccionaron artículos para ser incluidos en base a los títulos y resúmenes en inglés o francés. Se recogieron datos de los resultados y demografías de los pacientes, así como características de las instalaciones y los proveedores. Los análisis se redujeron a informes publicados a partir de 1990.

Resultados

Se identificaron 195 informes referentes a 192 instalaciones en 59 países. La mayoría eran hospitales académicamente afiliados en zonas urbanas. La mortalidad media en los servicios de urgencias era de 1,8% (rango intercuartílico, RIC: 0,2-5,1%). La mortalidad era relativamente alta en los centros pediátricos (mediana: 4,8%; RIC: 2,3-8,4%) y en el África subsahariana (mediana: 3,4%; RIC: 0,5-6,3%). La mediana de pacientes era de 30.000 al año (RIC: 10.296-60.000), la mayoría de los cuales eran jóvenes (mediana de edad: 35 años; RIC: 6,9-41,0) y hombres (mediana: 55,7%; RIC: 50,0-59,2%). El personal de la mayoría de los centros eran médicos en formación o médicos cuyo nivel de formación era indeterminado. Muy pocos de estos proveedores tenían una formación especializada en atención de emergencia.

Conclusión

Los datos disponibles en atención de emergencia en PIMB indican una gran carga de pacientes y mortalidad, en especial en el África subsahariana, donde una proporción sustancial de todas las muertes pueden ocurrir en los servicios de urgencias. La combinación entre una gran carga y la urgencia del tratamiento hacen de la atención de emergencia un área importante en la que centrarse de cara a intervenciones dirigidas a reducir la mortalidad en estos escenarios.

摘要

目的

旨在对中低收入国家 (LMIC) 中的急救护理进行系统评审。

方法

我们从 PubMed、CINAHL 和世界卫生组织 (WHO) 数据库中搜索了描述机构中急救护理的报告，并且从临床医生和研究人员网络中获取了未经发布的数据。 我们根据其英语或法语标题和摘要筛选了所包含的文章。 我们针对患者疗效和人口统计以及机构和提供方的特性提取了数据。 分析仅限于自 1990 年以来发布的报告。

结果

我们确定了涉及 59 个国家中 192 家机构的 195 份报告。 其中大部分为城市地区的学院附属医院。 急诊部内的平均死亡率为 1.8%（四分位差，IQR： 0.2 至 5.1%）。死亡率在儿科也相对较高（平均值： 4.8%；IQR： 2.3 至 8.4%），而且在撒哈拉以南的非洲死亡率也比较高（平均值： 3.4%；IQR： 0.5 至 6.3%）。患者平均为每年 30 000 例（IQR： 10 296 至 60 000），其中大部分为年轻人（平均年龄： 35 岁；IQR： 6.9 至 41.0）和男性（平均值： 55.7%；IQR： 50.0 至 59.2%）。大多数机构中的工作人员为实习医生或未指定培训水平的医生。 这些提供方中仅有非常少的一部分接受过急救护理方面的专业培训。

结论

中低收入国家 (LMIC) 中现有的急救护理数据表明患者数量和死亡率很高，特别是在撒哈拉以南的非洲，所有死亡中有相当大的一部分比例是发生在急诊部。 治疗量大并且具有紧急性这两个特点的结合让急救护理在我们采取以降低这些环境中的死亡率为目的的干预措施时成为关注的重点领域。

Резюме

Цель.

Систематизированный анализ неотложной помощи в странах с низким и средним уровнем доходов населения.

Методы.

В базах данных PubMed, CINAHL и Всемирной организации здравоохранения (ВОЗ) был проведен поиск отчетов по оказанию неотложной помощи в медицинских учреждениях. Кроме того, были получены неопубликованные данные от сети практикующих врачей и исследователей. Статьи отбирались по названию и аннотации на английском или французском языке. Отбирались данные по результатам лечения пациентов и демографические данные, а также информация о характеристиках медицинского учреждения и поставщиков медицинских услуг. Анализировались только отчеты, опубликованные с 1990 года.

Результаты.

Было отобрано 195 отчетов по 192 медицинским учреждениям в 59 странах. Большинство из этих учреждений являются академическими больницами, расположенными в городских районах. Средняя смертность в отделениях неотложной помощи составляла 1,8% (межквартильный размах, МКР: 0,2-5,1%). Смертность была относительно высокой в педиатрических медицинских учреждениях (медиана: 4,8%; МКР: 2,3-8,4%) и в Африке к югу от Сахары (медиана: 3,4%; МКР: 0,5-6,3%). Среднее количество пациентов составляло 30 000 человек в год (МКР: 10 296-60 000), большинство из которых были молодого возраста (средний возраст: 35 лет; МКР: 6,9-41,0) и мужского пола (медиана: 55,7%; МКР: 50,0-59,2%). Большинство медицинских учреждений были укомплектованы врачами-стажерами или врачами, уровень подготовки которых не указывался. Лишь небольшое число из рассмотренных поставщиков медицинских услуг обладали специальной подготовкой в области неотложной помощи.

Вывод.

Доступные данные по оказанию неотложной помощи в странах с низким и средним уровнем доходов свидетельствуют о большой численности поступающих больных и высоком уровне смертности, особенно в Африке к югу от Сахары, где существенная доля всех смертельных случаев приходится на отделения неотложной помощи. Высокий объем инцидентов и срочность необходимого лечения свидетельствуют о том, что неотложная помощь является одной из важнейших областей, на которую следует направить мероприятия по снижению уровня смертности в указанных условиях.

Introduction

Ebola virus disease,¹1 . Lamontagne F, Clément C, Fletcher T, Jacob ST, Fischer WA 2nd, Fowler RA. Doing today's work superbly well-treating Ebola with current tools. N Engl J Med. 2014 Oct 23;371(17):1565-6. http://dx.doi.org/10.1056/NEJMp1411310 PMID:25251518
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http://dx.doi.org/10.2471/BLT.11.093427... armed conflict³3 . Coghlan B, Brennan RJ, Ngoy P, Dofara D, Otto B, Clements M, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet. 2006 Jan 7;367(9504):44-51. http://dx.doi.org/10.1016/S0140-6736(06)67923-3 PMID:16399152
http://dx.doi.org/10.1016/S0140-6736(06)... and natural disasters⁴4 . Sharma D. Nepal earthquake exposes gaps in disaster preparedness.. Lancet 2015;385(9980):1819-20. Available from: Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60913-8.pdf [cited 2015 May 25].
http://www.thelancet.com/pdfs/journals/l... have recently strained systems for the provision of emergency care in low- and middle-income countries (LMICs). Expert groups have voiced concern about these systems' critical lack of surge capacity and resilience.⁵5 . High level meeting on building resilient systems for health in Ebola-affected countries, 2014 Dec 10-11, Geneva, Switzerland. Geneva: World Health Organization; 2015. Available from: Available from: http://www.who.int/csr/resources/publications/ebola/hs-meeting.pdf?ua=1 [cited 2015 Jan 5].
http://www.who.int/csr/resources/publica... Even in non-crisis situations, small surveys⁶6 . Wen LS, Xu J, Steptoe AP, Sullivan AF, Walline JH, Yu X, et al. Emergency department characteristics and capabilities in Beijing, China. J Emerg Med. 2013 Jun;44(6):1174-1179.e4. http://dx.doi.org/10.1016/j.jemermed.2012.07.083 PMID:23473821
http://dx.doi.org/10.1016/j.jemermed.201... ⁷7 . Wen LS, Oshiomogho JI, Eluwa GI, Steptoe AP, Sullivan AF, Camargo Jr CA. Characteristics and capabilities of emergency departments in Abuja, Nigeria. Emerg Med J. 2012 Oct;29(10):798-801. http://dx.doi.org/10.1136/emermed-2011-200695 PMID:22052953
http://dx.doi.org/10.1136/emermed-2011-2... and anecdotal accounts⁸8 . Gawande A. Dispatch from India.. N Engl J Med 2003 Dec 18;349(25):2383-6. http://dx.doi.org/10.1056/NEJMp038180 PMID:14681503
http://dx.doi.org/10.1056/NEJMp038180... hint at high volumes of critically-ill patients seeking emergency care in LMICs. This makes emergency care different from other health settings - including primary care - where doctors typically see only 8-10 ambulatory patients per day.⁹9 . Das J, Hammer J. Quality of primary care in low-income countries: Facts and economics. Annu Rev Econ. 2014;6(1):525-53.

In high-income countries, decades of advances in clinical science and care delivery have dramatically improved process efficiency and patient outcomes for a range of acute conditions.¹⁰10 . Rogers WJ, Canto JG, Lambrew CT, Tiefenbrunn AJ, Kinkaid B, Shoultz DA, et al. Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999. J Am Coll Cardiol. 2000 Dec;36(7):2056-63. http://dx.doi.org/10.1016/S0735-1097(00)00996-7 PMID:11127441
http://dx.doi.org/10.1016/S0735-1097(00)... ¹⁶16 . Kellermann AL, Hsia RY, Yeh C, Morganti KG. Emergency care: then, now, and next. Health Aff (Millwood). 2013 Dec;32(12):2069-74. http://dx.doi.org/10.1377/hlthaff.2013.0683 PMID:24301388
http://dx.doi.org/10.1377/hlthaff.2013.0... Despite increasingly urgent calls to apply lessons learnt in high-income countries to LMICs,¹⁷17 . Anderson PD, Suter RE, Mulligan T, Bodiwala G, Razzak JA, Mock C; International Federation for Emergency Medicine (IFEM) Task Force on Access and Availability of Emergency Care. World Health Assembly Resolution 60.22 and its importance as a health care policy tool for improving emergency care access and availability globally. Ann Emerg Med. 2012 Jul;60(1):35-44.e3. http://dx.doi.org/10.1016/j.annemergmed.2011.10.018 PMID:22326860
http://dx.doi.org/10.1016/j.annemergmed.... ¹⁹19 . Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda.. Ann Emerg Med 2010 Aug;56(2):142-9. http://dx.doi.org/10.1016/j.annemergmed.2010.01.013 PMID:20138398
http://dx.doi.org/10.1016/j.annemergmed.... a lack of data from the field has made it difficult to convince policy-makers to make major new investments in emergency care. Measuring the state of emergency care in LMICs is challenging, because care is delivered through a heterogeneous network of facilities and medical records are often incomplete, even for basic information such as patient identity and diagnosis.¹⁹19 . Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda.. Ann Emerg Med 2010 Aug;56(2):142-9. http://dx.doi.org/10.1016/j.annemergmed.2010.01.013 PMID:20138398
http://dx.doi.org/10.1016/j.annemergmed.... ²¹21 . Mowafi H, Dworkis D, Bisanzo M, Hansoti B, Seidenberg P, Obermeyer Z, et al. Making recording and analysis of chief complaint a priority for global emergency care research in low-income countries. Acad Emerg Med. 2013 Dec;20(12):1241-5. http://dx.doi.org/10.1111/acem.12262 PMID:24283813
http://dx.doi.org/10.1111/acem.12262...

Because of these challenges, studies of emergency care in LMICs have been limited to small, ad hoc efforts, in individual facilities, that were focused on individual acute diseases and conditions.²²22 . Robison J, Ahmed Z, Durand C, Nosek C, Namathanga A, Milazi R, et al. Implementation of ETAT (Emergency Triage Assessment And Treatment) in a central hospital in Malawi. Arch Dis Child. 2011;96 Suppl 1:A74-5. http://dx.doi.org/10.1136/adc.2011.212563.174
http://dx.doi.org/10.1136/adc.2011.21256... ²⁸28 . Wen LS, Geduld HI, Nagurney JT, Wallis LA. Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned.. Acad Emerg Med 2011 Aug;18(8):868-71. http://dx.doi.org/10.1111/j.1553-2712.2011.01131.x PMID:21843223
http://dx.doi.org/10.1111/j.1553-2712.20... We systematically reviewed all available evidence on emergency care delivery to guide future research on - and improvements of - emergency health systems in LMICs.

Methods

Systematic search

We did a systematic review (PROSPERO: CRD42014007617) - following PRISMA guidelines²⁹29 . Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009 Jul 21;6(7):e1000100. http://dx.doi.org/10.1371/journal.pmed.1000100 PMID:19621070
http://dx.doi.org/10.1371/journal.pmed.1... - to identify quantitative data on the delivery of emergency care to an undifferentiated patient population in all LMICs categorized as such in 2013.³⁰30 . Data: country and lending groups [Internet]. Washington: World Bank; 2013. Available from: Available from: http://data.worldbank.org/about/country-classifications/country-and-lending-groups [cited 2013 Aug 20].
http://data.worldbank.org/about/country-... To increase capture, we also included the names of the autonomous or semi-autonomous geographical areas recognized by the World Bank³⁰30 . Data: country and lending groups [Internet]. Washington: World Bank; 2013. Available from: Available from: http://data.worldbank.org/about/country-classifications/country-and-lending-groups [cited 2013 Aug 20].
http://data.worldbank.org/about/country-... and then disaggregated any relevant data obtained for such areas. For each country or subregion, we searched PubMed, CINAHL and World Health Organization (WHO) regional indices,³¹31 . Global health library [Internet].; Geneva: World Health Organization 2014. Available from: Available from: http://www.globalhealthlibrary.net/php/index.php [cited 2014 May 1].
http://www.globalhealthlibrary.net/php/i... using "emerg*" plus the country or area name as the search term. We wished to identify studies of emergency care, irrespective of location, patient complaint or provider specialty. We performed similar searches in Google Scholar but only searched within article titles. We also identified non-indexed journals that regularly published manuscripts on emergency care (available from the corresponding author) and screened every article in every issue of these journals manually. Searches were conducted between 12 August 2013 and 30 May 2014.

We screened reports based on their titles and abstracts in English or French. The full-text potentially relevant articles were retrieved, irrespective of language or date of publication. Since the purpose of our review was to synthesize recent evidence on emergency care, the findings summarized below relate only to data published after 1989. A summary of our observations on data that were published before 1990 is available from the corresponding author. We retained studies describing the delivery of any emergency care in a health facility to adult or paediatric patients, irrespective of the presenting complaint or condition. For each retained article, we conducted backward and forward reference searches: we screened the references cited and, using Google Scholar, we also identified and screened publications that cited the article. We excluded studies that focused on specific conditions or subsets of emergency patients unless they also provided data on the overall population or facility. We also excluded studies that aggregated data from multiple facilities and general descriptions of the state of emergency care in a country. Despite the assistance of trained medical librarians, the full texts of some potentially relevant manuscripts could not be traced. In these cases, we used data from related abstracts or posters, when available.

Unpublished data

We presented the study protocol and early results at the 2013 African Federation for Emergency Medicine consensus conference. We made use of this presentation and our professional networks to request relevant unpublished data from clinicians in LMICs. Some clinicians, researchers and authors were not authorized to release data that allowed the study health facility or facilities to be identified. In these cases, we identified facilities only by their locations and ownership - i.e. academic, non-profit or for-profit.

Data extraction

We extracted data on the characteristics of each study facility: country, urban or rural setting, bed count, annual patient volume, ownership and highest level of provider training. We considered a provider to be an emergency physician if reference was made to specialty postgraduate training, board certification or practice within an independent department of emergency medicine. We recorded details of the study population - i.e. age, sex, number of subjects included in analysis, number who arrived by ambulance - the sampling method and key patient outcomes. The latter included the inpatient admission and mortality within the emergency department, the percentages of patients recorded as brought in dead, or dead on arrival, and the length of time each patient stayed in the emergency department.

We created a database containing aggregated study data. When multiple publications described a single facility, we merged them to create a single record that, for each variable of interest, contained the most recently published data available. We stratified facilities using World Bank regions³⁰30 . Data: country and lending groups [Internet]. Washington: World Bank; 2013. Available from: Available from: http://data.worldbank.org/about/country-classifications/country-and-lending-groups [cited 2013 Aug 20].
http://data.worldbank.org/about/country-... and considered separately those facilities that only served paediatric populations. If data from a single facility were available disaggregated by age group, we summarized quantitative metrics for adult and paediatric patients separately. Full lists of the included studies and the data extracted and a full description of the study protocol are available from the corresponding author.

Descriptive analysis

We calculated summary statistics for all relevant metrics that were reported consistently across studies: bed count, annual patient volume, admission and mortality within the emergency department. We made an a priori decision not to perform a formal meta-analysis. Instead, our systematic analysis was meant to capture the distribution of metrics across populations - e.g. adult versus paediatric - and World Bank regions - e.g. Africa versus Asia - as well as global patterns. We thus present means - or medians with interquartile ranges (IQR) - disaggregated by country or region, as appropriate. Statistical analyses were performed using Stata/MP (StataCorp. LP, College Station, United States of America).

Results

Fig. 1 shows the results of our literature search. Of the 195 relevant published studies identified (Table 1; available at: http://www.who.int/bulletin/volumes/93/14/07-148338), 170 (87%) were descriptive reports on hospital-based emergency departments whereas the other 25 (13%) described the impact of an intervention. We obtained relevant unpublished data on a further 16 facilities. After combining multiple reports from the same facility and separating paediatric and adult data - for the three facilities with disaggregated data - we had data on 192 individual facilities in 59 countries. Of the 192 facilities, 107 (56%) were academically affiliated, 11 (6%) were in rural areas and 36 (19%) served paediatric patients exclusively; in the remaining 38, facility type could not be identified. Further information on the health facilities is available from the corresponding author.

Table 2 presents the key metrics for the facilities. Median mortality within the emergency departments - of the 65 facilities that reported the relevant data - was 1.8% overall and higher in the 19 paediatric facilities (4.8%) than in the 46 adult or general facilities (0.7%). Across World Bank regions that we investigated, mortality was highest in sub-Saharan Africa (3.4%; IQR: 0.5-6.3%; n= 44), especially in east, central or west Africa (4.8%; IQR: 3.3-8.4%; n= 30). Paediatric facilities in sub-Saharan Africa had a median mortality of 5.1% (IQR: 3.5-11.1%; n= 15). Mortality in emergency facilities was also high in Latin America. Two facilities in Brazil were major contributors to this high rate, with mortality of 7.4%³²32 . Peres RR, Lima SBS, de Souza Magnago TSB, Shardong AC, da Silva Ceron MD, Prochnow A, et al. Perfil clinico-epidemiologico dos pacientes internados no pronto-socorro de um hospital universitario. Rev Saúde (Santa Maria). 2013;39(1):77-86. Available from: Available from: http://cascavel.ufsm.br/revistas/ojs-2.2.2/index.php/revistasaude/article/view/5518 [cited 2014 Jan 10]. Portuguese.
http://cascavel.ufsm.br/revistas/ojs-2.2... and 3.9%.³³33 . Ribeiro RCHM, Rodrigues CC, Canova JCM, Rodrigues CDS, Cesarino CB, Júnior OLS. Stay and outcome of the clinical and surgical patient in the emergency service. Rev Enferm (Lisboa). 2013;7(9):5426-32. Available from: Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/4886/pdf_3390 [cited 2014 Jan 10].
http://www.revista.ufpe.br/revistaenferm... These centres also reported long inpatient stays: one facility reported a median length of stay of three days,³²32 . Peres RR, Lima SBS, de Souza Magnago TSB, Shardong AC, da Silva Ceron MD, Prochnow A, et al. Perfil clinico-epidemiologico dos pacientes internados no pronto-socorro de um hospital universitario. Rev Saúde (Santa Maria). 2013;39(1):77-86. Available from: Available from: http://cascavel.ufsm.br/revistas/ojs-2.2.2/index.php/revistasaude/article/view/5518 [cited 2014 Jan 10]. Portuguese.
http://cascavel.ufsm.br/revistas/ojs-2.2... whereas the other reported that 21% of patients stayed in the emergency department for more than five days.³³33 . Ribeiro RCHM, Rodrigues CC, Canova JCM, Rodrigues CDS, Cesarino CB, Júnior OLS. Stay and outcome of the clinical and surgical patient in the emergency service. Rev Enferm (Lisboa). 2013;7(9):5426-32. Available from: Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/4886/pdf_3390 [cited 2014 Jan 10].
http://www.revista.ufpe.br/revistaenferm... Lengths of stay were only reported for 15 facilities and for these, the median value was 7.7 hours (IQR: 3.3-40.8). As mortality data were only available for nine of these 15 facilities, it was not possible to formally investigate the relationship between length of stay and mortality. The five sub-Saharan African facilities that recorded length of stay reported a median stay of 17 hours (IQR: 16.9-18.0). Additional data comparing mortality, patient volumes and admission are available from the corresponding author.

Median annual patient volume was 30 021 (IQR: 10 296-60 000) among 173 facilities reporting these data. Volume was lower in the nine rural facilities (16 468; IQR: 3429-44 395) than in the 164 urban ones (31 000; IQR: 10 994-61 313). The 17 paediatric facilities in Sub-Saharan Africa had relatively low patient volumes with a median annual patient volume of 3129 (IQR: 2009-7479). The median inpatient admission was 20% (IQR: 10-43%; n= 78) and the median number of beds in the emergency department was 14 (IQR: 8-22; n= 60). The median age of patients attending non-paediatric facilities was 35 years (IQR: 6.9-41.0; n= 51) and a median of 55.7% (IQR: 50.0-59.2%; n= 93) were male. The corresponding values for paediatric facilities were 3.2 years (IQR: 2.8-3.4; n= 13) and 58.3% (IQR: 55.4-60.1%; n= 27), respectively.

Table 3 summarizes the training of providers staffing the 102 facilities for which provider data were available. Care in 67 (66%) of these facilities was provided either by trainees or by physicians whose level of training was not specified. In only 29 (28%) of facilities were attending or consultant-level physicians available full-time; in 19 other facilities, physicians were only available in daytime hours. Eighteen facilities were staffed by specialty-trained emergency physicians, but in only four facilities were emergency physicians available at all times - one in the United Republic of Tanzania (unpublished observations, 2014), one in Pakistan³⁴34 . Rehmani R. Emergency section and overcrowding in a university hospital of Karachi, Pakistan. J Pak Med Assoc. 2004 May;54(5):233-7. PMID:15270179 and two in Nicaragua.³⁵35 . Gaitan M, Mendez W, Sirker NE, Green GB. Growing pains: status of emergency medicine in Nicaragua.. Ann Emerg Med 1998 Mar;31(3):402-5. http://dx.doi.org/10.1016/S0196-0644(98)70355-5 PMID:9506502
http://dx.doi.org/10.1016/S0196-0644(98)... One facility provided specialized emergency training to non-physician providers staffing the emergency department.³⁶36 . Tiemeier K, Bisanzo M, Dreifuss B, Ward KC.; Global Emergency Care Collaborative. Ward KC. The effect of geography and demography on outcomes of emergency department patients in rural Uganda.. Ann Emerg Med 2013;62(4):S99-99. http://dx.doi.org/10.1016/j.annemergmed.2013.07.096
http://dx.doi.org/10.1016/j.annemergmed.... In another facility, medical students practising alone were primarily responsible for providing emergency care during most of the day.³⁷37 . Mabiala-Babela JR, Senga P. Consultations de nuit aux urgences pédiatriques du CHU de Brazzaville, Congo. (Nighttime attendance at the Pediatric Emergency Room of the University Hospital Centre in Brazzaville, Congo). Med Trop. 2009 Jun;69(3):281-5. PMID:19702153 Patients had to navigate through a wide range of options to obtain emergency care and financial factors played a major role in determining what kind of care they received (details available from the corresponding author).

Discussion

While only a small set of metrics on the delivery of emergency care were reported consistently across facilities, we were able to draw some conclusions on the state of emergency care in low-resource settings.

First, large numbers of patients presented to health facilities seeking emergency care. While there was a wide range in annual patient volumes - from just 451 in a paediatric emergency department in Nigeria³⁸38 . Duru C, Peterside O, Akinbami F. Pattern and outcome of admissions as seen in the paediatric emergency ward of the Niger Delta University Teaching Hospital Bayelsa State, Nigeria. Niger J Paediatr. 2013;40(3):232-7. Available from Available from http://www.ajol.info/index.php/njp/article/view/89985 [cited 2015 May 2].
http://www.ajol.info/index.php/njp/artic... to 273 182 in a general emergency department in Turkey³⁹39 . Eroglu SE, Toprak SN, Urgan O, Onur OE, Denizbasi A, Akoglu H, et al. Evaluation of non-urgent visits to a busy urban emergency department. Saudi Med J. 2012 Sep;33(9):967-72. PMID:22964808 - they were approximately 10 times higher than the corresponding caseloads observed in primary care settings in sub-Saharan Africa and Asia.⁹9 . Das J, Hammer J. Quality of primary care in low-income countries: Facts and economics. Annu Rev Econ. 2014;6(1):525-53.

Second, patients seeking emergency care were generally young and free of chronic conditions. This is in contrast to the growing burden of elderly patients with multiple chronic conditions seen in the emergency departments of high-income countries.⁴⁰40 . Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010 Aug 11;304(6):664-70. http://dx.doi.org/10.1001/jama.2010.1112 PMID:20699458
http://dx.doi.org/10.1001/jama.2010.1112... Therefore, interventions to decrease mortality and morbidity in emergency settings of LMICs could dramatically increase life-years saved and productivity.

Third, the mortality recorded in emergency departments in LMICs was many times higher than generally reported in high-income countries.⁴⁰40 . Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010 Aug 11;304(6):664-70. http://dx.doi.org/10.1001/jama.2010.1112 PMID:20699458
http://dx.doi.org/10.1001/jama.2010.1112... ⁴²42 . Health, United States, 2012: with special feature on emergency care. Hyattsville: National Center for Health Statistics; 2013. Available from: Available from: http://www.cdc.gov/nchs/data/hus/hus12.pdf [cited 2014 Jan 15].
http://www.cdc.gov/nchs/data/hus/hus12.p... A recent report on emergency departments in the USA documented a mean mortality within the departments of 0.04%.⁴⁰40 . Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010 Aug 11;304(6):664-70. http://dx.doi.org/10.1001/jama.2010.1112 PMID:20699458
http://dx.doi.org/10.1001/jama.2010.1112...

Fourth, most providers of emergency care in LMICs had no specialty training in emergency care. This observation was expected given the general shortages in human resources for health in most of these countries.⁴³43 . Crisp N, Chen L. Global supply of health professionals.. N Engl J Med 2014 Mar 6;370(10):950-7. http://dx.doi.org/10.1056/NEJMra1111610 PMID:24597868
http://dx.doi.org/10.1056/NEJMra1111610... Such shortages may be particularly pronounced in emergency settings, where the work is demanding and salaries are often poor. Most governments do not include emergency medicine in their medical education priorities.

What implications do these results have for LMICs? We made a rough calculation for Nigeria, where we identified relevant studies in 21 facilities and mean annual patient volume of 3000 and 5-7% mortality. If we assume that the approximately 1000 teaching and general hospitals⁴⁴44 . Nwakeze NM, Kandala N-B. The spatial distribution of health establishments in Nigeria. Afr Popul Stud. 2011;25(2):680-96. in the country have the same mean annual patient volume and mortality, then out of the 1.6 million deaths recorded annually in Nigeria⁴⁵45 . Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.. Lancet 2012 Dec 15;380(9859):2095-128. http://dx.doi.org/10.1016/S0140-6736(12)61728-0 PMID:23245604
http://dx.doi.org/10.1016/S0140-6736(12)... an estimated 10-15% occur in emergency departments. This estimate - and the observation that most emergency departments in LMICs are run by providers with no speciality training in emergency care - illustrates the opportunity to improve emergency care in LMICs. It is likely that relatively simple interventions to facilitate triage and improve patient flow, communication and the supervision of junior providers (Box 1) could lead to reductions in the mortality associated with emergency care.⁴⁶46 . Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia.. J Trauma 2003 Jun;54(6):1188-96. http://dx.doi.org/10.1097/01.TA.0000073609.12530.19 PMID:12813342
http://dx.doi.org/10.1097/01.TA.00000736... ⁴⁹49 . Robison JA, Ahmad ZP, Nosek CA, Durand C, Namathanga A, Milazi R, et al. Decreased pediatric hospital mortality after an intervention to improve emergency care in Lilongwe, Malawi. Pediatrics. 2012 Sep;130(3):e676-82. http://dx.doi.org/10.1542/peds.2012-0026 PMID:22891229
http://dx.doi.org/10.1542/peds.2012-0026...

Our data illustrate the unique cost-benefit profile of investments in emergency care. Although disease and injury prevention are key functions of all health systems, acute health problems - e.g. myocardial infarction, sepsis and trauma - continue to occur in all countries. With the same amount of resources, it is likely that more lives could be saved in a paediatric emergency facility with mortality between 12% and 21%⁵⁰50 . Okolo SN, Ogbonna C, Bode-Thomas F. Healthcare service auditing and intervention in an emergency paediatric unit.. Niger J Paediatr 2002;29(3):71-4. http://dx.doi.org/10.4314/njp.v29i3.12026
http://dx.doi.org/10.4314/njp.v29i3.1202... ⁵²52 . Bamgboye EA, Familusi JB. Mortality pattern at a children's emergency ward, University College Hospital, Ibadan, Nigeria. Afr J Med Med Sci. 1990 Jun;19(2):127-32. PMID:2115728 than in paediatric primary-care clinics in similar settings - which generally see just a few critically-ill children per clinic per week (unpublished observations, 2015). There is thus a clear case for investing in emergency care in LMICs, to complement existing efforts to strengthen primary and preventive care.

Implications for policy

What is needed to strengthen emergency care in LMICs? First, a better understanding of the conditions that drive patients to seek such care is crucial. We documented high patient volumes and mortality but did not identify the diseases or the conditions that drive these metrics. While useful estimates of the burden of acute conditions may be produced in mathematical models,⁵³53 . Kobusingye OC, Hyder AA, Bishai D, Joshipura M, Romero Hicks E, Mock C. Emergency Medical Services. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease control priorities in developing countries. 2nd ed.; Washington: World Bank 2006. pp. 1261-79. the setting of specific clinical and policy priorities remains difficult because of the scarcity of relevant data.

Second, once we have a better understanding of the burden of acute disease, interventions known to be effective in high-income settings - e.g. trauma resuscitation training - must be adapted to LMICs and critically assessed. Some effective interventions to decrease mortality in emergencies (Box 1) may only require the improved use of existing system components, with the minimal input of new material resources. However, assessing the effectiveness of such interventions by rigorous experimental or quasi-experimental methods requires additional funding. Although before-and-after comparisons may be easier, they are also vulnerable to a range of biases.⁵⁴54 . Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA. 2014 Dec 10;312(22):2401-2. http://dx.doi.org/10.1001/jama.2014.16153 PMID:25490331
http://dx.doi.org/10.1001/jama.2014.1615...

Third, international organizations must accelerate efforts to develop consensus on the essential components of systems for emergency care. Policy-makers who wish to assess their emergency systems and set priorities for development need technical guidance. WHO's framework on systems of trauma care is one useful model for this broad agenda.⁵⁵55 . Guidelines for essential trauma care.; Geneva: World Health Organization 2004. Available from: Available from: http://whqlibdoc.who.int/publications/2004/9241546409.pdf?ua=1 [cited 2015 May 11].
http://whqlibdoc.who.int/publications/20...

Finally, improvements to emergency care in LMICs will require advances in data collection. The development of a minimum set of indicators for emergency care in LMICs would facilitate research and quality improvement.²¹21 . Mowafi H, Dworkis D, Bisanzo M, Hansoti B, Seidenberg P, Obermeyer Z, et al. Making recording and analysis of chief complaint a priority for global emergency care research in low-income countries. Acad Emerg Med. 2013 Dec;20(12):1241-5. http://dx.doi.org/10.1111/acem.12262 PMID:24283813
http://dx.doi.org/10.1111/acem.12262... Several actors are improving platforms for data collection in LMICs. For example, the African Federation for Emergency Medicine is building consensus around a medical chart that has been purpose-designed to capture data for clinicians, administrators and researchers in LMICs. A novel data collection platform has been implemented for trauma care in a large teaching hospital in the United Republic of Tanzania, with promising early results. The systematic integration of routine data collection into care delivery settings should help ensure that interventions are - and remain - effective.

Limitations

The most important limitation of our study is the general paucity of data on emergency care. After screening over 40 000 published reports, we identified relevant data from only 192 facilities spread across 59 LMICs. For comparison, there are about 5000 emergency departments in the USA.⁵⁶56 . Muelleman RL, Sullivan AF, Espinola JA, Ginde AA, Wadman MC, Camargo Jr CA. Distribution of emergency departments according to annual visit volume and urban-rural status: implications for access and staffing.. Acad Emerg Med 2010 Dec;17(12):1390-7. http://dx.doi.org/10.1111/j.1553-2712.2010.00924.x PMID:21122024
http://dx.doi.org/10.1111/j.1553-2712.20... The facilities we identified were largely urban and academic - as might be expected given that our search strategy relied mainly on published reports. Broader reporting biases may also have affected our results. For example, facilities with fewer resources may be relatively unlikely to collect and publish data and facilities with exceptionally high levels of mortality may be relatively unlikely to publish those levels. Thus, our results are likely to present an optimistic view of the state of emergency care in LMICs.

Regional comparisons must be viewed with caution, given the geographical variation in facility characteristics and reporting practices. For example, emergency departments in which patients have exceptionally long lengths of stay will probably also have exceptionally high mortality - since patients who stay longer in the department are more likely to die in the department. Although a lack of relevant data prevented us from investigating this relationship, the median length of stay in our sample - albeit in the small number of facilities that reported lengths of stay - was only 7.7 hours. It therefore seems unlikely that prolonged stays alone could have accounted for the high levels of mortality that we observed.

Other limitations were our search strategy, which relied on the presence of at least one word that began with "emerg" in the title, keywords or abstract of an article. While this made a difficult search problem tractable, it may also have excluded some relevant studies. Also, lack of data standardization across facilities and countries probably biased our results. For example, standardized measures of mortality - e.g. the percentage of patients that died with 24 hours of their presentation - were seldom reported, probably because of the difficulties of following-up patients after they leave the emergency department. The maximum age for a so-called paediatric patient also varied widely across studies, from five to 19 years.⁵⁷57 . Miranda NA, Rezende BD, Oliveira J de SF, Franco MBS, Kawata LS. Caracterização de crianças atendidas no pronto-socorro de um hospital universitário. Gestão Saude. 2012;4(1):1631-45. [Portuguese.] ⁵⁸58 . Peixoto B de V, Piazzetta E, Rischini FA, Guimarães MN, Cuziol M, Lodo PB, et al. [The harsh reality of children and youth emergency care showing the health status of a city.] Rev Paul Pediatr. 2013 Jun;31(2):231-6. http://dx.doi.org/10.1590/S0103-05822013000200015 PMID:23828061 Portuguese.
http://dx.doi.org/10.1590/S0103-05822013...

Conclusion

Emergency facilities in LMICs serve a large, young patient population with high levels of critical illnesses and mortality. This suggests that emergency care should be a global health priority. The cost-benefit ratio for improvements in emergency care is likely to be highly favourable, given the high volume of patients for whom high-quality care could be the difference between life and death. There are likely to be substantial opportunities to improve care and impact outcomes, in ways that could be rigorously evaluated with manageable sample sizes.

Acknowledgements

Ziad Obermeyer and Stephanie Kayden are also affiliated with Brigham and Women's Hospital, Boston. Other members of the Acute Care Development Consortium: Mark Bisanzo (Global Emergency Care Collaborative, Uganda), Amit Chandra (Princess Marina Hospital, Gaborone, Botswana), Cindy Y. Chang (Harvard Affiliated Emergency Medicine Residency Boston, USA), Kirsten Cohen (New Somerset Hospital, Cape Town, South Africa), Joshua J Gagne (Brigham and Women's Hospital, Boston, USA), Eveline Hitti (American University of Beirut Medical Center, Beirut, Lebanon), Bonaventure Hollong (University of Cape Town, Cape Town, South Africa), Steven Holt (ER Consulting Inc, Johannesburg, South Africa), Vijay Kannan (University of Texas Southwestern Medical Center, Dallas, USA), Roshen Maharaj (King Dinuzulu Hospital Complex, Durban, South Africa), Roseda Marshall (John F. Kennedy Medical Center, Monrovia, Liberia), Hani Mowafi (Yale University School of Medicine, New Haven, USA), Michelle Niescierenko (Boston Children's Hospital, Boston, USA), Maxwell Osei-Ampofo (Komfo Anokye Teaching Hospital, Kumasi, Ghana), Junaid Razzak (Aga Khan University Hospital, Karachi, Pakistan), Rasha Sawaya (Childrens National Medical Center, Washington, USA), Hendry R Sawe (Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania), Stefan Smuts (Mediclinic Southern Africa, South Africa), Sukhjit Takhar (Brigham and Women's Hospital, Boston, USA), Eva Tovar-Hirashima (Harvard Affiliated Emergency Medicine Residency, Boston, USA), Benjamin Wachira (Aga Khan University Hospital, Nairobi, Kenya)

References

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