Academic journal article Bulletin of the World Health Organization

Emergency Care in 59 Low- and Middle-Income Countries: A Systematic review/Les Soins D'urgence Dans 59 Pays a Revenu Faible Ou Intermediaire: Examen systematique/La Atencion De Emergencia En 59 Paises De Ingresos Medios Y Bajos: Revision Sistematica

Academic journal article Bulletin of the World Health Organization

Emergency Care in 59 Low- and Middle-Income Countries: A Systematic review/Les Soins D'urgence Dans 59 Pays a Revenu Faible Ou Intermediaire: Examen systematique/La Atencion De Emergencia En 59 Paises De Ingresos Medios Y Bajos: Revision Sistematica

Article excerpt

Introduction

Ebola virus disease, (1) cholera, (3) armed conflict (3) and natural disasters (4) 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. (5) Even in non-crisis situations, small surveys (6,7) and anecdotal accounts (8) 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. (9)

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. (10-16) Despite increasingly urgent calls to apply lessons learnt in high-income countries to LMICs, (17-19) 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. (19-21)

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. (22-28) 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 guidelines (29)--to identify quantitative data on the delivery of emergency care to an undifferentiated patient population in all LMICs categorized as such in 2013. (30) To increase capture, we also included the names of the autonomous or semi-autonomous geographical areas recognized by the World Bank (30) 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, (31) 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. …

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