1. Bradley Dreifuss, MD University of Arizona Assistant Professor of Emergency Medicine Director of Rural, Border and Global Emergency Medicine Programs Global Emergency Care Collaborative Executive Board Member brad@globalemergencycare.org @dreifussmd Management of Acute Surgical Patients by Non-Physician Emergency Care Practitioners in Rural Uganda http://globalemergencycare.org/

2. 2 Outline Introduction to GECC Emergency care definition EC system & chain of survival for surgical dz Emergency Departments and the service provided Emergency Care Practitioner Training Program Future of GECC & Emergency Care in Uganda

3. 3 Global Emergency Care Collaborative Global Emergency Care Collaborative (GECC) is a Non-Profit organization formed in 2007 by U.S. Emergency Medicine-trained Physicians Mission: Support Ugandan stakeholders and the development high-quality, sustainable emergency healthcare training and services throughout Uganda

4. 4 Emergency Care Emergency Care: The initial evaluation, diagnosis, treatment and disposition of any patient requiring expeditious surgical, medical or psychiatric care Trauma Acute HIV emergencies OB emergencies Intra-abdominal surgical pathology Pneumonia and diarrheal emergencies Orthopedic emergencies Management of acute exacerbations of chronic disease Emergency Departments provide a valuable service

5. 5 Emergency Care System  Community lay-person first response  Ambulance service response  (if available)  Acute care - Emergency Department  Definitive care - surgical, medical

6. 6 Bystand er First Aid Emergency Service Dispatch Field based Critical Intervention Transport to Appropriate Unit Early Resuscitation Rapid Diagnosis Early Specialist Intervention Intensive CareRehabilitation Right Person, Right Place, Right Time Emergency Chain of Survival Field Based Care Facility Based Care Definitive Care

7. 7 Why Support Emergency Care?

8. 8 Role of Emergency Care at Hospital Triage and stabilization of patients Patients for routine follow up or minor illness are seen in OPD Sickest patients sent to Emergency Department The faster acutely sick patients are evaluated and stabilized, the higher the survival Maximizes efficiency of care Critically ill patients not waiting in line Pts requiring minor surgical or medical interventions can be discharged home after ED visit Sick surgical patients are resuscitated before going to theatre Resuscitation of medical patients begins early, prior to ICU

9. 9 Emergency Care and EC Provider Role Emergency Department = “Front Door” to hospital Without a functional front door, people enter and exit from multiple locations. An ED needs trained providers, or it becomes a bottle neck for patients receiving timely quality care

10. 10 EC – Services To Support Surgical Team Appropriately triage patients Identify those needing simple surgical procedures Treat and disposition appropriately Identify acute surgical conditions Begin resuscitation Begin appropriate antibiotics (when indicated) Perform bedside imaging Order and interpret labs Notify surgeons of acute patients Coordinate transfer of patient to Operating Theatre

11. 11 GECC Initial Site Karoli Lwanga Hospital 150 bed hospital in Rukungiri district, Southwest rural Uganda 6 bed Emergency Department 300-700 patients per month

12. 12 GECC Activities Developing the “Emergency Care Practitioner” (ECP) cadre mid-level healthcare provider capable of managing many acute conditions In collaboration and at direction of MOH and MUST stakeholders Data collection on each pt visit Injury surveillance Clinical presentation 72hr patient follow-up Partnering w/ Mbarara University of Science & Technology Develop an ECP Diploma Program Expanding the ECP training program Partnering w/ the Uganda MOH formally recognize & develop the ECP as a healthcare cadre Supporting MUST and Makerere for EM MMED

13. 13 Emergency Care Practitioners In 2009, started an ongoing 2 year task-shifting program to create access to quality emergency care. Innovative Curriculum is two years with graduated responsibility and transition to supervisory role. Nurses   Mid-Level Emergency Care Practitioner Physicians to focus on surgical, ward & OPD care

14. 14 Data Collection and Surveillance/Outcomes Over 30,000 patient visits Injury Surveillance (forms by Injury Control Ctr of Uganda) Clinical data from ED visit; disposition; observations (VS) 72hr Follow-up program Mortality analysis using case fatality rates

15. 15 Study of Acute Surgical Patient Management by ECPs in a Rural ED Prelim retrospective review 9/2009-10/2014: surgical patients transferred from ED directly to theatre Variables of interest: Time to theatre Pre-operative interventions (fluids, abx, pain meds) ED based diagnostics Operative diagnosis/intervention 3 day mortality

16. 16 Study of Acute Surgical Patient Management by ECPs in a Rural ED - Results 25,891 pts seen in ED 153 were sent to theater 135 w/complete data 64.4% male 47.4% after OPD closed 49.5% traumatic injury 25.9% w/SIRS criteria 5.9% w/MAP <60 48.5% intra-abdominal pathology 69.6% w/pre-op testing/imaging Bedside Ultrasound – 31.1% Xray – 8.9%

17. 17 Study of Acute Surgical Patient Management by ECPs in a Rural ED – Results Time in ED (data available for 76 patients) Median: 96.5min (Range 16-371min) Mean: 131.6min (SD: ± 95.1min) Trauma patients mean: 96.7min (SD: ± 75.6min) Non-trauma: 171.9min (SD: ± 101.7min) 3day follow-up and mortality: 114 (84.4%) with successful f/u 107 (79.3%) confirmed alive at 3d 7 (5.2%) confirmed as dead at 3d Intent to treat mortality = 20.7% (if those missing are dead)

18. 18 Study of Acute Surgical Patient Management by ECPs in a Rural ED – Conclusions Specialty trained non-physician ECPs practicing in a dedicated ED, appear to augment acute surgical care Rapid diagnosis Pre-operative resuscitation/treatment Coordinating and expediting pt disposition to theatre Providing minor surgical care in the ED, where appropriate Future research directions: Research on diagnostic reliability and quality of minor surgical care Examination of the impact of the ECPs on hospital/surgical system’s operational efficiency, cost effectiveness, and surgeon/anesthetist satisfaction.

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20. 20 Conclusions and Future Directions Establishment of Emergency Care training programs, including use of contextually appropriate task ‐ shifting, could increase access to optimal surgical care. earlier diagnosis, better pre-operative resuscitation. A well designed ED with specialty trained clinicians (physicians and non-physicians) provides a health-system strengthening service ensuring that the Emergency surgical and medical “Chains of Survival” remain intact. Development and implementation of Ugandan university- based Emergency Medicine MMED programs are crucial to development of an emergency care system to optimize surgical care and capacity.

21. 21 Well, what’s a lecture w/o a ___ __ _____? Recognize the health-system- strengthening function of emergency care Unite the efforts of Emergency Care and Global Surgical Capacity development To optimize pt care Create efficient/effective health systems Create cadres of providers at multiple levels – with quality training and oversight

22. 22 Global Emergency Care Collaborative Sustainable & Scalable EM education in resource limited settings Promotional Video: http://vimeo.com/17141360 Contact with Questions: contact@globalemergencycare.org Brad Dreifuss – brad@globalemergencycare.orgbrad@globalemergencycare.org http://globalemergencycare.org/ Twitter: @globalemergcare Thank you for your time!