Prehospital Care System Research Articles

Association Between Delay to First Shock and Successful First-Shock Ventricular Fibrillation Termination in Patients With Witnessed Out-of-Hospital Cardiac Arrest.

In patients with out-of-hospital cardiac arrest who present with an initial shockable rhythm, a longer delay to the first shock decreases the probability of survival, often attributed to cerebral damage. The mechanisms of this decreased survival have not yet been elucidated. Estimating the probability of successful defibrillation and other factors in relation to the time to first shock may guide prehospital care systems to implement policies that improve patient survival by decreasing time to first shock. Patients with a witnessed out-of-hospital cardiac arrest and ventricular fibrillation (VF) as an initial rhythm were included using the prospective ARREST registry (Amsterdam Resuscitation Studies). Patient and resuscitation data, including time-synchronized automated external defibrillator and manual defibrillator data, were analyzed to determine VF termination at 5 seconds after the first shock. Delay to first shock was defined as the time from initial emergency call until the first shock by any defibrillator. Outcomes were the proportion of VF termination, return of organized rhythm, transportation with return of spontaneous circulation, and survival to discharge, all in relation to the delay to first shock. A Poisson regression model with robust standard errors was used to estimate the association between delay to first shock and outcomes. Among 3723 patients, the proportion of VF termination declined from 93% when the delay to first shock was <6 minutes to 75% when that delay was >16 minutes (Ptrend<0.001). Every additional minute in VF from emergency call was associated with 6% higher probability of failure to terminate VF (adjusted relative risk, 1.06 [95% CI, 1.04-1.07]), 4% lower probability of return of organized rhythm (adjusted relative risk, 0.96 [95% CI, 0.95-0.98]), and 6% lower probability of surviving to discharge (adjusted relative risk, 0.94 [95% CI, 0.93-0.95]). Every minute of delay to first shock was associated with a significantly lower proportion of VF termination and return of organized rhythm. This may explain the worse outcomes in patients with a long delay to defibrillation. Reducing the time interval from emergency call to first shock to ≤6 minutes could be considered a key performance indicator of the chain of survival.

ECPR-the evolving role in cardiac arrest.

Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) to restore blood circulation in patients during refractory cardiac arrest. So far, ECPR is not the standard of care but has become part of clinical routine for select patients in many places. As ECPR is ahighly invasive support option associated with considerable risks for fatal complications, premature use in patients who may have return of spontaneous circulation should be avoided. However, the selection criteria for ECPR are still evolving, as the search for evidence is ongoing. Recent randomized controlled trials of different ECPR strategies support its use within integrated systems built around highly specialized ECPR centers. The ECPR caseload is an important predictor of patient survival, and continuous training is key for evidence-based quality of care. Typical complications after ECPR include vascular injury or malposition of cannulas, thrombotic complications, hemolysis, and bleeding events that require early detection and interdisciplinary management. When provided by highly specialized and well-trained expert teams in dedicated ECPR centers within integrated pre-hospital and intra-hospital emergency care systems, ECPR may improve survival in select patients with refractory cardiac arrest. This article is freely available.

Financing and cost-effectiveness of emergency medical services in low- and middle-income countries

In 2023, the 76th World Health Assembly declared coordinated emergency, critical, and operative care services fundamental for comprehensive universal health coverage in low- and middle-income countries. With increasing mortality from noncommunicable diseases, an organized emergency care system has the capacity to treat a variety of conditions with a common set of resources, optimizing per-unit cost efficiency by applying economies of scope and increasing cost-effectiveness. However, the financing and cost-effectiveness of emergency medical services remain poorly understood despite affordability and financial barriers comprising some of the most significant obstacles to development. Cost-effectiveness analyses generate incremental cost-effectiveness ratios for comparison against per-capita gross domestic product thresholds to determine cost-effectiveness, promoted by the World Health Organization’s Choosing Interventions that are Cost-Effective program. Incremental cost-effectiveness ratios may be used as context-specific indicators of value alongside budget impact and feasibility considerations. Currently, there are few high-quality cost-effectiveness studies of emergency care in low- and middle-income countries, demonstrating significant methodologic heterogeneity, little geographic diversity, neglecting descriptions of assumptions used in cost-effectiveness calculations and comparators used, and lacking incremental cost-effectiveness ratios for comparison. The assessment of emergency care cost-effectiveness is challenging, given the significant breadth of conditions encountered and difficulty in projecting subsequent impact. Without improved epidemiologic surveillance and data-collection infrastructure, data inputs for cost-effectiveness calculations will remain limited. Future efforts should practice standard cost-effectiveness methodologies to permit comparison of incremental cost-effectiveness ratios across interventions and settings while incorporating trauma registry data to longitudinally track patient outcomes over sufficient time horizons to determine impact. New indices that expand the scope of analysis to capture broader secondary impacts of emergency care for future cost-effectiveness studies are needed. In this article, we summarize the key steps for economic evaluations for prehospital care systems and recommend considerations for future prehospital emergency care cost-effectiveness analyses, determining the optimal structure for financing mechanisms well-suited to resource-limited settings are critical for future investigation.

Impact of COVID-19 Pandemic on Health and Life Emergencies Resulting from Illness Cases and Injuries-A Preliminary Study.

Background: Despite organised efforts, the COVID-19 pandemic had a significant impact on the health status of the population and health services including the emergency medical system. The objective of the study was to investigate, based on the Emergency Medical Teams' (EMT) interventions, the impact of the COVID-19 pandemic on health and life emergencies resulting from illness cases and injuries of Polish females and males. Material and Methods: The data under analysis concern EMT interventions carried out in central and eastern Poland from 1 January 2017 to 31 December 2022 (n = 226,038). The study used descriptive statistics, the Mann-Whitney U Test, and the Chi-square test. Results: A significant increase was observed in the proportion of EMT interventions (p < 0.001) to patients with illness cases (80.30% vs. 83.17%) and a decrease in interventions to patients with injuries (19.70% vs. 16.83%) during the pandemic as compared to the pre-pandemic period. As for illness cases, the patients' ages during both periods were similar (Me = 66.00 vs. 66.00, p = 0.071). On the other hand, during the pandemic, injuries mainly affected elderly patients as compared to the pre-pandemic period (Me = 50.00 vs. 47.00, p < 0.001). The increase in the proportion of EMT interventions to patients with illness cases and the decrease in patients with injuries during the pandemic, as compared to the pre-pandemic period, concerned the area of intervention, patient's sex, and age. During the pandemic period, a significantly lower proportion of patients transported to the hospital (p < 0.001) and an increase in the proportion of patients left at the place of call (p < 0.001) were noted. Conclusions: The restrictions aimed at preventing the spread of the SARS-CoV-2 virus contributed to a reduced number of injuries without, however, reducing the number of illness cases. During the pandemic, the elderly were affected by injuries. The study indicates the need for further in-depth analyses to prepare the pre-hospital care system in Poland for the occurrence of other or similar emergencies.

Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

ObjectiveA vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods...

Emergency medical services impact evaluation approaches in low and middle-income countries

There is a strong need to critically consider the neocolonial context when discussing the impact evaluation of Eemergency Medical Services (EMS) systems in many low to middle-income countries. Many of these countries have faced exploitation and settler colonialism, and in today’s world the aftermath of these political–economic unequal power dynamics persists through neocolonialism. “Solutions” to prehospital care and related donor-driven development sector aid programs are typically orchestrated by high-income countries in the Global North, many of whom directly benefited from centuries of colonizing the Global South. This perpetuates the financial and technocratic dependency of many low to middle-income countries.Traditional Global North–led impact assessment typically revolves around mortality outcomes. This is problematic because singularly tracking mortality can obscure the influence of important factors at play beyond the emergency response incident itself, such as morbidity and socioeconomic privilege. This is why process indicators such as response times and economic impacts on first responders and communities are crucial. Hence, instead of trying to develop a one-size-fits-all impact assessment criteria for all the diverse prehospital care system contexts across the world, it is important to focus on enabling bottom-up, community-led, and participatory approaches to finding context-tailored solutions. A key element of this should be the co-creation of the measures of success themselves with the community stakeholders.Such a decolonial holistic approach may then help put the spotlight on often neglected important measures, such as the inclusion of underprivileged minorities in emergency response and the level of protection against catastrophic health care expenditure built into EMS systems. In doing so, it can encourage a monitoring and evaluation shift from short-term mortality to long-term wellbeing, taking into account cultural contexts about what “wellbeing” entails. Furthermore, it is important to challenge the taken-for-granted notion that in low to middle-income countries, EMS systems are solely for trauma and medical emergencies. It is also important to consider (with the dialogue led by the local stakeholders) what sustainability would look like, and how resources accordingly should be allocated, in those regions in low to middle-income countries where there is political and economic volatility as a consequence of continuing neocolonial hegemony.

The practice and determinants of ambulance service utilization in pre-hospital settings, Jimma City, Ethiopia

BackgroundIn pre-hospital setting, ambulance provides emergency care and means of transport to arrive at appropriate health centers are as vital as in-hospital care, especially, in developing countries. Accordingly, Ethiopia has made several efforts to improve accessibility of ambulances services in prehospital care system that improves the quality of basic emergency care. Yet, being a recent phenomenon in Ethiopia, empirical studies are inadequate with regard to the practice and determinants of ambulance service utilization in pre-hospital settings. Hence, this study aimed to assess the ambulance service utilization and its determinants among patients admitted to the Emergency Departments (EDs) within the context of pre-hospital care system in public hospitals of Jimma City.MethodA cross-sectional study design was used to capture quantitative data in the study area from June to July 2022. A systematic sampling technique was used to select 451 participants. Interviewer-administered questionnaire was used to collect data. Data analysis was done using SPSS version 26.0; descriptive and logistic regressions were done, where statistical significance was determined at p < 0.05.ResultsAmbulance service was rendered to bring about 39.5% (of total sample, 451) patients to hospitals. The distribution of service by severity of illnesses was 48.7% among high, and 39.4% among moderately acute cases. The major determinants of ambulance service utilization were: service time (with AOR, 0.35, 95%CI, 0.2-0.6 for those admitted to ED in the morning, and AOR, 2.36, 95%CI, 1.3-4.4 for those at night); referral source (with AOR, 0.2, 95%CI, 0.1-0.4 among the self-referrals); mental status (with AOR, 1.9, 95%CI, 1-3.5 where change in the level of consciousness is observed); first responder (AOR, 6.3 95%CI, 1.5-26 where first responders were the police, and AOR, 3.4, 95%C1, 1.7-6.6 in case of bystanders); distance to hospital (with AOR,0.37, 95%CI, 0.2-0.7 among the patients within ≤15km radius); and prior experience in ambulance use (with AOR, 4.1,95%CI, 2.4-7).ConclusionAlthough the utilization of ambulance in pre-hospital settings was, generally, good in Jimma City; lower levels of service use among patients in more acute health conditions is problematic. Community-based emergency care should be enhanced to improve the knowledge and use of ambulance services.

Predictive modelling of transport decisions and resources optimisation in pre-hospital setting using machine learning techniques.

The global evolution of pre-hospital care systems faces dynamic challenges, particularly in multinational settings. Machine learning (ML) techniques enable the exploration of deeply embedded data patterns for improved patient care and resource optimisation. This study's objective was to accurately predict cases that necessitated transportation versus those that did not, using ML techniques, thereby facilitating efficient resource allocation. ML algorithms were utilised to predict patient transport decisions in a Middle Eastern national pre-hospital emergency medical care provider. A comprehensive dataset comprising 93,712 emergency calls from the 999-call centre was analysed using R programming language. Demographic and clinical variables were incorporated to enhance predictive accuracy. Random Forest (RF), Support Vector Machine (SVM), Extreme Gradient Boosting (XGBoost), and Adaptive Boosting (AdaBoost) algorithms were trained and validated. All the trained algorithm models, particularly XGBoost (Accuracy = 83.1%), correctly predicted patients' transportation decisions. Further, they indicated statistically significant patterns that could be leveraged for targeted resource deployment. Moreover, the specificity rates were high; 97.96% in RF and 95.39% in XGBoost, minimising the incidence of incorrectly identified "Transported" cases (False Positive). The study identified the transformative potential of ML algorithms in enhancing the quality of pre-hospital care in Qatar. The high predictive accuracy of the employed models suggested actionable avenues for day and time-specific resource planning and patient triaging, thereby having potential to contribute to pre-hospital quality, safety, and value improvement. These findings pave the way for more nuanced, data-driven quality improvement interventions with significant implications for future operational strategies.

Management of traumatic brain injury in Africa: challenges and opportunities.

Traumatic brain injury (TBI) is a major public health concern globally, with significant implications for morbidity, mortality, and long-term disability. While extensive research has been conducted on TBI management in high-income countries, limited attention has been given to the specific challenges and opportunities faced by healthcare systems in sub-Saharan Africa (SSA). This perspective study aims to provide a comprehensive overview of the current status of TBI management in SSA, focusing on the unique challenges and potential opportunities for improvement. The findings highlight several key challenges faced by SSA healthcare systems in managing TBIs, including limited resources, inadequate infrastructure, and a shortage of trained healthcare professionals. Furthermore, social and cultural factors, such as ignorance of driving laws, financial constraints, and limited access to modern technology services. However, the study also identifies potential opportunities for improving TBI management in SSA. These include strengthening healthcare infrastructure, enhancing pre-hospital care and transportation systems, and increasing public awareness and education about TBI. This perspective study emphasizes the urgent need for tailored interventions and strategies to address the unique challenges faced by SSA in managing TBIs. Addressing the challenges and opportunities in brain injury management in SSA requires a comprehensive approach which can be through investing in health infrastructure, addressing socio-economic inequalities, implementing prevention strategies, and fostering evidence-based research collaboration. Through this, the region can significantly improve TBI care and outcomes, thereby improving the well-being of people affected by TBI in SSA.

Redesigning Prehospital Care: Fiji's Response to the COVID-19 Pandemic.

The benefits of emergency care systems in low- and middle-income countries are well-described. Passed in the wake of the coronavirus disease 2019 (COVID-19) pandemic, the World Health Assembly (WHA) Resolution 76.2 emphasizes the importance of communication, transportation and referral mechanisms, and the linkages between communities, primary care, and hospital care. Literature describing prehospital care and ambulance system development is scarce, with little data on the effectiveness and cost effectiveness of different options. Prehospital care systems in Pacific Island countries are under-developed. In Fiji, out-of-hospital care is fragmented with an uncoordinated patchwork of ambulance providers. There is no scope of practice or training requirement for providers and no patient care records. There are no data relating to demand, access, and utilization of ambulance services.In response to a surge of COVID-19 cases in 2021, the Fiji government created a Prehospital Emergency Care Coordination Center (PHECCC) in the capital Suva, which was operational from July-October 2021. Access was via a toll-free number, whereby the public could receive a medical consultation followed by phone advice or dispatch of an ambulance for a home assessment, followed by transportation to hospital, if required. The PHECCC also provided coordination of inter-facility transport and retrieval of the critically ill.The system that was created met many of the prehospital care standards set by emergency care leaders in the region and created the first dataset relating to ambulance demand and utilization. This is the first article to document prehospital system development in the Pacific region.

Revitalizing Emergency Care Ecosystem in India through Comprehensive Transformation and Innovative Solutions

Emergency care is a critical pillar of healthcare systems, serving as the initial point of contact for individuals facing acute conditions. However, consistent access to prompt emergency care remains a challenge in many regions, particularly low and middle-income countries (LMICs), where a substantial burden of disease is attributed to emergencies. This paper explores the emergency care ecosystem in India, emphasizing the role of first responders, effective communication, ambulance services, and trained healthcare staff. It also highlights challenges, solutions, technological advancements, and the benefits of implementing an emergency surveillance system to improve emergency care services. The multifaceted approach includes strengthening pre-hospital care systems, equipping communities with basic first aid skills, optimizing ambulance services, strengthening formal education and training in emergency care, harnessing technological solutions, data-driven insights, innovative approaches, and telemedicine. These efforts collectively aim to establish a seamless continuum of care, minimize patient treatment delays, and ensure that healthcare professionals are both incentivized and adequately prepared for high-stress emergency environments. Additionally, addressing violence against healthcare professionals and ensuring equitable access to emergency care are crucial components of the transformation agenda. This transformation is not only essential for saving lives, reducing disabilities, and advancing universal health coverage but also addresses a critical gap in India's healthcare landscape by enhancing the efficiency and accessibility of emergency care services.

Prehospital Emergency Care: A Cross-Sectional Survey of First-Aid Preparedness Among Layperson First Responders in Northern Uganda.

Uganda has a high incidence of road traffic accidents and high mortality rates, yet lacks a mature prehospital emergency care system. Our study addresses this gap by assessing the experiences, training, and confidence in providing first aid (FA) among diverse layperson first responders in Northern Uganda, expanding beyond previous research, which was limited to Central Uganda and specific occupational groups. We conducted a cross-sectional survey among layperson first responders of various occupations in Gulu City, Acholi sub-region, Uganda. Data on socio-demographics, training, experiences, knowledge, and confidence in FA were collected. We included 396 participants, of whom 81.6% (n=323) were male, 47.0.6% (n=186) were aged 21-30 years, 59.3% (n=235) had obtained a secondary level of education, 23.7% (n=94) were commercial motorcyclists, and 45.7% (n=181) had work experience of >5 years. The majority (85.4%, n=338) had witnessed acute illness/trauma. Accidents/bleeding were the most commonly witnessed cases (68.6%, n=232), followed by burn injuries (10.1%, n=34). Most participants (52.3%, n=207) had attended FA training. Only 20.5% (n=81) had obtained an above-average score (≥70%). The majority (67.9%, n=269) were confident in providing FA. Lack of knowledge and skills (61.4%, n=78), fear of taking health risks (18.9%, n=24), and legal implications (7.1%, n=9) were the major reasons for not being willing to confidently give FA. Factors associated with above-average knowledge were tertiary education and being confident in providing FA, while training in FA and prior experience in giving FA were associated with confidence in giving FA. In this study, laypeople in Northern Uganda exhibited a high level of FA training. However, low confidence in providing FA is attributed to inadequate knowledge, fear of health risks, and legal concerns. Therefore, future efforts should focus on assessing FA practices in diverse regions and promoting formal FA training.

Bystander intervention is associated with reduced early mortality among injury victims in Cameroon.

Despite high injury mortality rates, Cameroon currently lacks a formal prehospital care system. In other sub-Saharan African low and middle-income countries, Lay First Responder (LFR) programs have trained non-medical professionals with high work-related exposure to injury in principles of basic trauma care. To develop a context-appropriate LFR program in Cameroon, we used trauma registry data to understand current layperson bystander involvement in prehospital care and explore associations between current non-formally trained bystander-provided prehospital care and clinical outcomes. The Cameroon Trauma Registry (CTR) is a longitudinal, prospective, multisite trauma registry cohort capturing data on injured patients presenting to four hospitals in Cameroon. We assessed prevalence and patterns of prehospital scene care among all patients enrolled the CTR in 2020. Associations between scene care, clinical status at presentation, and outcomes were tested using univariate and multivariate logistic regression. Injury severity was measured using the abbreviated injury score. Data were analyzed using Stata17. Of 2212 injured patients, 455 (21%) received prehospital care (PC) and 1699 (77%) did not receive care (NPC). Over 90% (424) of prehospital care was provided by persons without formal medical training. PC patients were more severely injured (p<0.001), had markers of increased socioeconomic status (p = 0.01), and longer transport distances (p<0.001) compared to NPC patients. Despite increased severity of injury, patients who received PC were more likely to present with a palpable pulse (OR = 6.2, p = 0.02). Multivariate logistic regression adjusted for injury severity, socioeconomic status and travel distance found PC to be associated with reduced emergency department mortality (OR = 0.14, p<0.0001). Although prehospital injury care in Cameroon is rarely performed and is provided almost entirely by persons without formal medical training, prehospital intervention is associated with increased early survival after injury. Implementation of LFR training to strengthen the frequency and quality of prehospital care has considerable potential to improve trauma survival.

Barriers and facilitators for developing a prehospital emergency care system evaluation tool (PEC-SET) for low-resource settings: a qualitative analysis

ObjectivesStrengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a...

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan

PurposeIn Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a “doctor car”. Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.MethodsA nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.ResultsThis study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065–1.415]).ConclusionUsing nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Seeking and reaching emergency care: A cross sectional household survey across two Liberian counties.

The overwhelming burden of morbidity and mortality from injury and medical conditions requiring acute care are borne by low- and middle-income countries lacking accessible, quality care systems. Current evidence suggests the lack of prehospital care systems likely contributes to this disproportionate burden. As an initial step in a longitudinal, collaborative effort to strengthen the chain of survival for emergency conditions in Liberia, baseline attitudes and behaviors in accessing and utilizing emergency care were characterized. A multistage, proportional, cluster sampling frame was employed to conduct a cross-sectional, community-based survey of 800 households across rural Lofa County and the greater capital (Monrovia) metropolitan area. The primary outcome was facility-based utilization of emergency care within the 12 months prior to survey administration. 43.9% of individuals surveyed reported a visit to an emergency unit in the last year. Multivariable logistic regression revealed increased adjusted odds of facility-based emergency care utilization in households that were low-income, non-English-speaking, lacking electricity, or had a non-durable roof. Among these individuals, 23.6% had sought care from a community health worker, family/friend, clinic, pharmacy, or traditional healer prior. The majority of persons seeking care do so without ambulance services. 34.8% of all households have called a community member for a medical emergency, but 88.9% of survey respondents report no first aid training and cite barriers to rendering aid. This represents the first household survey to assess the perceptions and utilization of emergency care in Liberia. Formal pre-hospital care provision is limited and substantial barriers to emergency care access exist. First aid training and acceptance is lacking, despite frequent reliance on community-based aid during emergencies.

Developing a prehospital care service in a low-resource setting: Barriers and solutions.

Prehospital care (PHC) is critical to the comprehensive and effective functioning of a healthcare system. Given the disproportionate burden of both communicable and non-communicable diseases in low-income nations, its significance cannot be understated. In spite of this, many of these nations lack a comprehensive PHC system. Setting up a cost-effective PHC system in this environment can be difficult and necessitate a variety of stakeholders at various healthcare delivery system levels. Therefore, it is necessary to consider these anticipated barriers and identify feasible solutions for its execution. This will assist in creating a PHC system that is suited to the local needs and achieve sustainable and global health goals. This paper describes the challenges and solutions to establishing a prehospital care service in a low-resource setting.

Implementation and evaluation of a pilot WHO community first aid responder training in Kinshasa, DR Congo: A mixed method study

IntroductionPrehospital care in many low- and middle-income countries is underdeveloped and needs strengthening for improved outcomes. Where formal prehospital care systems are under development, integration of a layperson first responder programme may help improve access for those in need. The World Health Organization recently developed the Community First Aid Responder (CFAR) learning program in support of this system, providing that it may require adaptation to be contextually suitable and sustainably implemented at country level. This study assesses a pilot WHO CFAR course in Kinshasa, Democratic Republic of Congo, to inform future rollouts and related research. MethodsWe conducted a 3-day in-person pilot CFAR training with 42 purposively selected community health workers. Data collection involved quantitative and qualitative phases. The first consisted of structured pre- and post-training surveys, and a course evaluation by participants. The second consisted of two focus group discussions involving purposively selected community health workers in one group, and a convenience sample of course instructors and organisers in the other. Perceptions regarding course content, perceived knowledge acquisition and self-confidence gain were analysed using descriptive statistics for the quantitative data and content analysis for qualitative data. ResultsCourse participants were predominantly male (76.3 %) with a median age of 42 years and most (80.5 %) had no prior first aid training. Most were satisfied that the learning objectives were reached, the logistics were adequate, and that the content and teaching language were appropriately tailored to local context. The majority (94.7 %) found the 3-day duration insufficient. There was a significant self-confidence gain regarding first aid skills (average 17.9 % in pre- to 95.3 % in post-training, p < 0.001). Favourable opinions on the course structure, content, logistics and teaching methods were noted. ConclusionA CFAR course pilot was successfully conducted in Kinshasa. The course is appropriate for context and well received by participants. It can form a key component of developing prehospital care systems in resource-constrained settings.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study

Introduction Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. Methods This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. Results Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. Conclusion In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

A qualitative assessment of stakeholder perspectives on barriers and facilitators to emergency care delays in Northern Tanzania through the Three Delays.

Emergency conditions cause a significant burden of death and disability, particularly in developing countries. Prehospital and Emergency Medical Services (EMS) are largely nonexistent throughout Tanzania and little is known about the community's barriers to accessing emergency care. The objective of this study was to better understand local community stakeholder perspectives on barriers, facilitators, and potential solutions surrounding emergency care in the Kilimanjaro region through the Three Delays Model framework. A qualitative assessment of local stakeholders was conducted through semi-structured focus group discussions (FGDs) from February to June 2021 with five separate groups: hospital administrators, emergency hospital workers, police personnel, fire brigade personnel, and community health workers. FGDs were conducted in Kiswahili, audio recorded, and translated to English verbatim. Two research analysts separately coded the first two FGDs using both inductive and deductive thematic analysis. A final codebook was then created to analyze the remaining FGDs. A total of 24 participants were interviewed. Thematic analysis revealed that participants identified significant barriers within the Three Delays Model as well as identified an additional delay centered on community members and first aid provision. Perceived delays in the decision to seek care, the first delay, were financial constraints and the lack of community education on emergency conditions. Limited infrastructure and reduced transportation access were thought to contribute to the second delay. Potential barriers to receiving timely appropriate care, the third delay, included upfront payments required by hospitals and emergency department intake delays. Suggested solutions focused on increasing education and improving communication and infrastructure. The findings outline barriers to accessing emergency care from a stakeholder perspective. These themes can support recommendations for further strengthening of the prehospital and emergency care system. Due to logistical constraints, emergency care workers interviewed were all from one hospital and patients were not included.