INTRODUCTION

Community based perceptions of emergency care in communities lacking formalized emergency medicine systems

MC Broccoli, EJB Calvello, AP Skog, M Twomey, C Cunningham, B Wachira, LA WallisJohns Hopkins University School of Medicine, Baltimore, Maryland, USA

Zambia and Kenya face an increasing burden of acute disease, yet have underdeveloped emergency care systems. Patients presenting to facilities with acute, time-sensitive illness and injury are cared for by undertrained healthcare providers.(1-11) Before any interventions to strengthen systems are implemented, an assessment of the current need for emergency care is needed.

Currently, there is no publically accessible tool available for conducting an assessment of out-of-hospital and pre-hospital care needs in a community with no existing system.(12-18)

AIMS AND OBJECTIVES

METHODS

First Aim: Create a community based emergency care assessment tool that can be customized for any region.

Second Aim: Identify what community members perceive as the critical interventions necessary for pre-hospital emergency care systems improvement.

This was accomplished using focus groups structured around the following study objectives.

1. Determine the current pattern of out of hospital emergency care delivery at the community level.

2. Identify the communities’ experiences with emergency conditions and the barriers they face when trying to access care.

3. Discover community generated solutions to the paucity of emergency care in urban and rural settings.

Phase 1: Zambia Pilot

6 Zambian healthcare providers were trained over 3 days to conduct semi-structured focus groups; they also refined the focus group script for use in Zambian communities.

21 focus groups with 183 total participants were conducted in 3 provinces, to thematic saturation.

Phase 2: Kenya

4 Kenyan healthcare providers were trained over 4 days to conduct semi-structured focus groups; the focus group script was refined for Kenya based on their input and Zambian experiences .

60 focus groups with 528 total participants were conducted in the 8 Kenyan provinces, to thematic saturation.

Thematic analysis of community member focus groups identified frequency of emergencies, perceptions of emergency care, perceived barriers to emergency care, and ideas for potential interventions.

RESULTS CONCLUSIONS

IMPLICATIONS AND NEXT STEPS

Community members in Zambia and Kenya experience a wide range of medical emergencies, and rely on family members, neighbors, and good Samaritans for assistance with transportation to medical facilities and with acute stabilization.

People in these communities already assist each other during medical emergencies, and are willing to help in the future.

Interventions can be made at all levels of the healthcare system to improve emergency care access, including:

Increasing community awareness about medical emergencies and teaching community first aid courses.

Implementation of triage and prioritization at healthcare facilities and training providers in the basics of emergency care.

Zambia

The results of this needs assessment were presented to the Zambian Defense Force and the Ministry of Health (MoH).

The Zambian Defense Force is currently creating two separate emergency care curricula: to educate their healthcare workers on identifying and caring for acutely ill and injured persons, and to educate communities on basic emergency awareness and first aid.

Kenya

A report will be created and used to advocate for and to inform targeted community-based solutions for strengthening the Kenyan emergency care system.

Advocacy will be aimed at community education initiatives and triage implementation in healthcare facilities.

The focus group training tool and focus group script will be made available for use in other countries looking to assess the emergency care needs of their citizens.

This qualitative tool can also be combined with a more quantitative assessment to provide a more comprehensive picture of the current status of emergency care in a given location.

Assistance and Willingness to Help

Community-Identified Solutions in Zambia Most community members felt that community first aid

training would improve their access to emergency care.

Other solutions included:

Having a triage system to prioritize emergency cases

Increasing the number of healthcare facilities

Improving the hours of existing facilities

Increasing the number of ambulances

Having one emergency phone number that is known by all

Paying healthcare providers more to incentivize them to work better and to not leave their clinics to see private patients

Community-Identified Solutions in Kenya Many community members felt that their access to emergency care could be

improved by:

Increasing the number and availability of healthcare facilities

Building capacity at the community level by re-instating the role of the community health worker and educating the entire community on recognizing and responding to medical emergencies

Having a central, functional number that is known by all and can be called during an emergency

Educating healthcare providers on how to care for emergency patients and increasing the number of healthcare providers so they have the capacity to do so

Improving the availability of medications at healthcare facilities

Having dedicated, affordable transportation for those suffering a medical emergency

“Mostly what I think the government should do is teach us on the ground so incase an emergency arises we can assist the person and do first aid before help arrives, because I think most people lack proper first aid skills and experience. So I think they need to train the general public on first aid it would save many lives.” – Kenya, Nyanza Province

“If there was a separate emergency section it’d help as opposed to being made to queue with everyone else.” – Kenya, Coast Province

“Emergencies should be treated as emergencies and be prioritized.” – Kenya, Eastern Province

Community Exposure to Medical Emergencies

Zambia Kenya

Described emergencies as: Sudden, unexpected, needing care urgently Needing rapid treatment, pre-hospital treatment, or in-hospital treatmentSudden, unexpected, urgent

Participants who had personally witnessed a medical emergency:

69% 74%

Participants who had witnessed >3: 39% 36%

Common emergencies experienced: Labor complications, trauma, seizures, lacerations, fractures, syncope, burns, snake bites, and difficulty breathing.

Road traffic accidents, loss of consciousness, burns, trauma from assaults, traumatic bleeding, blunt trauma, difficulty breathing, and labor.

Common means of transportation to healthcare facility:

Private cars, bicycles, taxis, and walking Private cars, motorcycles, and ambulances

Zambia Kenya

Would help during a medical emergency: 85% 85%

Have helped someone previously: 73%

How participants would help: By providing transport to the hospital, first aid, money, advice, support, and comfort.

By by providing transport to the hospital, providing medical care, calling for help, and giving the victim money.

Barriers to Emergency Care

Zambia Kenya

• Transportation (inability to find transportation, long distances to healthcare facilities, high cost)

• Healthcare providers did not triage or prioritize acute patients, were overburdened, or had bad attitudes.

• Lack of community knowledge about medical emergencies and emergency care: many do not know what to do when they encounter an emergency.

• Cost of medical care• Long queues in hospitals, no system for prioritization of acute

patients, no sense of urgency from providers• Difficulty obtaining transport • Lack of resources in facilities• Lack of community knowledge about medical emergencies and

emergency care