Multimethod examination of the status of emergency care in Ugandan health facilities
Emergency care is a vital component of any functioning healthcare system, required to rapidly address a vast array of time-critical conditions and thereby reduce their associated morbidity and mortality. At present a wide global discrepancy exists, with Low and Middle-Income Countries (LMICs) experiencing unacceptably high rates of mortality from treatable emergency conditions. Uganda has one of the highest burdens of injury and emergency presentations on the African continent, yet has no formal integrated emergency care system. With the majority of literature and evidenced experience of emergency care system implementation derived from high-income countries, this thesis addresses the knowledge gap of the current status and provision of emergency care to patients across Ugandan healthcare facilities. This research explores four interrelated questions, focused on the following key themes; the epidemiology, clinical characteristics, disease burden, acuity and initial management of emergency care patients. The findings relevant to these questions are viewed through the lens of the fourth and final question which assesses the emergency care delivery capability of Uganda regional facilities. The paucity of LMIC emergency system research is demonstrated through a narrative literature review, which outlines the wide array of barriers to the current delivery of emergency care in low- resource contexts. The subsequent systematic literature review establishes the lack of published data regarding all-cause epidemiology and characteristics of emergency care patients in LMICs in sub-Saharan Africa, demonstrating the critical investment required to produce quality data and analyse current emergency care delivery in low-resource contexts. These initial two chapters build an overview of the context within which the research chapters of the thesis can be viewed. To address the current status of emergency care in the country, using key data points from the systematic review, a cross-sectional study was performed. The study utilised retrospective emergency patient chart and emergency care register data at eleven sites across Uganda, representing all geographical regions. A standardised World Health Organisation survey of emergency care delivery capacity was performed at eight of the sites which are designated Regional Referral Hospitals. Data was collected in May and June 2019 for the time period from November 2018 to April 2019 during a 5-week data collection period. All data was monitored through a quality assurance and sign off process. All data was cleaned and processed according to defined protocols. During the analysis a novel system for disease burden coding was developed specifically for the low- income emergency care context, in addition to a novel mechanism for retrospectively triaging trauma patients. A total of 4704 emergency patient records and eight emergency care capability surveys were analysed from the eleven sites. Most of the patient profile was similar to that found in studies from other countries in the sub-Saharan region, though data demonstrated significant proportions of paediatric and geriatric patients in the dataset. Attendance rates were low in comparison to high-income countries, though there was a high proportion of out-of-hours attendances. There was a high admission rate in the dataset but a lower than anticipated mortality rate, including in trauma. A significant proportion of patients had multiple diagnoses listed in their patient record, with 30.1% being infective in origin and 25.7% injury. Triage, vital signs and examination findings were poorly documented throughout. Overuse of IV antibiotics was found throughout all conditions both infective and non-infective in the dataset. An overrepresentation of male patients was found in the trauma subset, even in paediatric age groups, with road traffic accident the most common mechanism of injury. A high proportion (36.8%) patients were retrospectively triaged in the highest ‘red’ triage category. These retrospective red triage patients were more likely to be closely monitored than yellow patients. Malaria, respiratory and gastrointestinal were the most common infectious sources. Emergency unit mortality was low in infection patients, but significant following admission. Deficiencies in Ugandan emergency care capability were found across all components of service delivery. Many facilities lacked the ability to perform even basic emergency care interventions alongside a universal lack of 24-hour access to comprehensive diagnostic capability. Commonly identified barriers to emergency care capability were human resource, training, equipment and consumables. The first study of its kind across multiple sites in Ugandan, the findings presented are invaluable in providing a new insight and in-depth description of emergency care provision in a system in its infancy. This thesis describes the multidimensional nature of emergency care delivery, ascertaining the interrelated and complex components of the system that must be concurrently addressed by policy makers if quality care is to be consistently provided.