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Emergency Department-Based HIV Testing Services and Self-Testing Programs: A Qualitative Study of Healthcare Providers and Patients in Kenya
- Adam Aluisio, Scarlett Bergam, Janet Sugut, Kate Guthrie, John Kinuthia, Michael Mello
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s137
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- May 2023
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Introduction:
Young people in Sub-Saharan Africa, especially males, have been insufficiently engaged in HIV Testing Services (HTS). In Kenya, these persons are often treated in emergency departments (EDs) for injuries, a healthcare interaction where HTS including HIV self-testing (HIVST) could be leveraged. There is, however, limited data from stakeholders on ED-HTS which impedes programmatic advancement.
Method:A qualitative study was completed to understand facilitators and challenges for ED-HTS and HIVST delivery in Kenya (12/2021-03/2022). Data were collected via 28 in-depth patient interviews (14 males and 14 females) who had been treated in the Kenyatta National Hospital (KNH) ED and through seven focus-group discussions conducted with 49 ED healthcare personnel (nurses, doctors, HIV testing counselors, and administrators). Transcripts were double-coded and thematically analyzed with Dedoose™ software using a parallel inductive and deductive approach to capture both a priori and emergent themes.
Results:Patients and providers viewed ED-HTS as a beneficial provision that was facilitated by engaged staff, education, perceived high HIV risk, and confidentiality. However, ED-HTS was limited by burdens on staff time and material resources, lacking systems integration, and patient illness severity. Facilitators of ED-HIVST delivery were perceived to have greater autonomy and confidentiality as well as lower health resource utilization. Challenges for ED-HIVST identified included patients’ concerns about HIVST accuracy and psychological stress, as well as providers’ concerns for loss to follow up and inability to complete confirmatory testing.
Conclusion:ED stakeholders are receptive to HTS and HIVST provisions. This data provides insight into the patient, provider, and systems aspects that can be leveraged in ED-based HTS to enhance program impacts via intervention functions in the forms of education, care integration, resource scaling, and solidified post-self-testing follow-up mechanisms.
Comparison of Injury Epidemiology and Treatments by Gender Among Persons Seeking Emergent Care in Kigali, Rwanda
- Adam Aluisio, Chantal Uwamahoro, Stephanie Garbern, Doris Uwamahoro, Lise Mumporeze, Catalina González Marqués
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s169
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- May 2023
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Introduction:
Variations in the incidence and patterns of injuries exist between genders which may impact treatments and outcomes. The study aimed to describe the epidemiology, treatments, and outcomes based on the gender of persons presenting with injuries to an Emergency Department (ED) in Kigali, Rwanda.
Method:This was a secondary analysis of a prospective cross-sectional study conducted in January-June 2021 at the Centre Hospitalier Universitaire de Kigali ED. Descriptive statistics were performed and variable comparisons based on binary gender self-designation (male or female) were conducted.
Results:A total of 601 patients were included in the analysis of whom 25.6% were female and 74.4% were male. Gender differences were found in the mechanism of injury with females more likely to be injured via falls (43.5% versus 23.0%, p=0.001), while males were more likely to be in a road traffic accident (52.6% versus 39.6%, p=0.006), have stab and/or laceration (9.0% versus 2.0%, p=0.004) or have been assaulted (6.9% versus 2.6%, p=0.047). Injury severity was not significantly different between genders based on the median Kampala Trauma Score and presence of triage hypotension. For treatments females were more likely to have been transported by prehospital services (87.7% versus 72.9%, p=0.001), but were less likely to received acute ED treatments of intubation, wound care, tourniquets, blood products, thoracostomy and point-of-care ultrasound during the first six hours of care (67.5% versus. 78.1%, p=0.009). Hospital admission was significantly greater among females as compared to males, (31.2% versus 41.8%, p=0.019) but no difference in mortality was observed (2.0% versus 1.3%, p=0.568).
Conclusion:This study provides data on differences in epidemiologic and care characteristics between males and females presenting for emergency injury care in Rwanda. These findings can inform future research and help the development of gender-centered healthcare delivery in Rwanda and other similar contexts.
Focused Needs Assessment and Tailored Training Pilot for Emergency Care Providers in Rwanda
- Naz Karim, Catalina Gonzalez Marques, Angela Zhang, Janette Baird, Mikaela Belsky, Jean Marie Uwitonze, Jeanne D'arc Nyinawankusi, Pascal Mugemangango, Zeta Mutabazi, Adam Aluisio
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- Journal:
- Prehospital and Disaster Medicine / Volume 38 / Issue S1 / May 2023
- Published online by Cambridge University Press:
- 13 July 2023, p. s160
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- May 2023
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Introduction:
In lower- and middle-income countries (LMIC), 45% of deaths could be prevented by implementation of emergency care systems. Prehospital care is critical for emergency medical services (EMS) worldwide, and basic affordable training improves EMS systems. This study conducted a needs assessment in addition to a tailored prehospital training intervention. Subsequent changes in prehospital care as well as patient outcomes were measured.
Method:Thirty providers identified through the prehospital medical command office participated. A prospective, nonrandomized interrupted time-series approach was utilized for a needs assessment and training intervention. Data collected included age, gender, training level, and a knowledge assessment, and was used to create an 18-hour training, with immediate and 11-month posttests. Prehospital process indicators evaluated on-the-ground application of skills, including airway intervention, intravenous fluid administration, and glucose administration. Linked prehospital and hospital care datasets allowed for evaluation of patient outcomes.
Results:Of 30 providers, 60% (n=18) female and 40% (n=12) male, 19 were nurses and 11 were nurse anesthetists. Median age was 36 and median years providing care was 10 (IQR: 7,11). 24 (80%) participants completed immediate and post-test assessments, showing a 56% (95%CI: 36.2, 75.8) relative increase in mean knowledge score across 12 core skills that was maintained across post-tests. 324 of 572 total patients transported to the ED during the study were transported during the pre-training period (56.4%). Prehospital oxygen administration for patients with a saturation level of <95% increased pre- to post-intervention (66.7% to 71.7%; Δ = 5.0%; Δ95%CI: 1.9, 8.1%).
Conclusion:This study is the first LMIC-based prehospital provider training efficacy study that includes analysis of patient outcomes and clinical process indicators. Results offer important insights on Rwanda’s prehospital care system and demonstrate that affordable, tailored educational interventions targeting process indicators have positive impacts on provider knowledge and practice.
Simulating a Vertical Evacuation of a NICU and PICU to Examine the Relationship Between Training and Preparedness
- Ramon E. Gist, Pia Daniel, Nizar Tejani, Andrew Grock, Adam Aluisio, Stephan Kohlhoff, Patricia Roblin, Bonnie Arquilla
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- Journal:
- Disaster Medicine and Public Health Preparedness / Volume 16 / Issue 5 / October 2022
- Published online by Cambridge University Press:
- 31 August 2021, pp. 1811-1813
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Objective:
The aim of this study was to implement pediatric vertical evacuation disaster training and evaluate its effectiveness by using a full-scale exercise to compare outcomes in trained and untrained participants.
Methods:Various clinical and nonclinical staff in a tertiary care university hospital received pediatric vertical evacuation training sessions over a 6-wk period. The training consisted of disaster and evacuation didactics, hands-on training in use of evacuation equipment, and implementation of an evacuation toolkit. An unannounced full-scale simulated vertical evacuation of neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) patients was used to evaluate the effectiveness of the training. Drill participants completed a validated evaluation tool. Pearson chi-squared testing was used to analyze the data.
Results:Eighty-four evaluations were received from drill participants. Forty-three (51%) of the drill participants received training and 41 (49%) did not. Staff who received pediatric evacuation training were more likely to feel prepared compared with staff who did not (odds ratio, 4.05; confidence interval: 1.05-15.62).
Conclusions:There was a statistically significant increase in perceived preparedness among those who received training. Recently trained pediatric practitioners were able to achieve exercise objectives on par with the regularly trained emergency department staff. Pediatric disaster preparedness training may mitigate the risks associated with caring for children during disasters.
Association Between Vitamin A Supplementation and Mortality Among Patients with Ebola Virus Disease: An International Multisite Cohort Study
- Adam Aluisio, Derrick Yam, Jillian L. Peters, Daniel K. Cho, Shiromi M. Perera, Stephen B. Kennedy, Foday Sahr, Stephanie Garbern, Tao Liu, Adam C. Levine
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- Journal:
- Prehospital and Disaster Medicine / Volume 34 / Issue s1 / May 2019
- Published online by Cambridge University Press:
- 06 May 2019, pp. s15-s16
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- May 2019
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Introduction:
Micronutrient supplementation is recommended in Ebola Virus Disease (EVD). However, there is limited data on its therapeutic impacts. This study evaluated the association between vitamin A supplementation and mortality outcomes in EVD patients.
Methods:This retrospective cohort study accrued patients with EVD admitted to five International Medical Corps run Ebola Treatment Units (ETU) in two countries from 2014-2015. Protocolized treatments with antimicrobials and micronutrients were used at all ETUs. However, due to resource limitations and care variations, only a subset of patients received vitamin A. Standardized data on demographics, clinical characteristics, malaria status, and Ebola virus RT-PCR cycle threshold (CT) values were collected. The outcome of interest was mortality compared between cases treated with 200,000 International Units of vitamin A on care days one and two and those not. Propensity scores (PS) based on the first 48-hours of care were derived using the covariates of age, duration of ETU function, malaria status, CT values, symptoms of confusion, hemorrhage, diarrhea, dysphagia, and dyspnea. Treated and non-treated cases were matched 1:1 based on nearest neighbors with replacement. Covariate balance met predefined thresholds. Mortality proportions between cases treated and untreated with vitamin A were compared using generalized estimating equations to calculate relative risks (RR) with associated 95% confidence intervals (CI).
Results:There were 424 cases analyzed, with 330 (77.8%) being vitamin A-treated cases. The mean age was 30.5 years and 57.0% were female. The most common symptoms were diarrhea (86%), anorexia (81%), and vomiting (77%). Mortality proportions among cases untreated and treated with vitamin A were 71.9% and 55.0%, respectively. In a propensity-matched analysis, mortality was significantly lower among cases receiving vitamin A (RR = 0.77 95%; CI:0.59-0.99; p = 0.041).
Discussion:Early vitamin A supplementation was associated with reduced mortality in EVD patients and should be provided routinely during future epidemics.
Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial
- Adam R. Aluisio, Pia Daniel, Andrew Grock, Joseph Freedman, Ajai Singh, Dimitrios Papanagnou, Bonnie Arquilla
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- Journal:
- Prehospital and Disaster Medicine / Volume 31 / Issue 5 / October 2016
- Published online by Cambridge University Press:
- 05 August 2016, pp. 516-523
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- October 2016
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Objective
In resource-constrained environments, appropriately employing triage in disaster situations is crucial. Although both case-based learning (CBL) and simulation exercises (SEs) commonly are utilized in teaching disaster preparedness to adult learners, there is no substantial evidence supporting one as a more efficacious methodology. This randomized controlled trial (RCT) evaluated the effectiveness of CBL versus SEs in addition to standard didactic instruction in knowledge attainment pertaining to disaster triage preparedness.
MethodsThis RCT was performed during a one-day disaster preparedness course in Lucknow, India during October 2014. Following provision of informed consent, nursing trainees were randomized to knowledge assessment after didactic teaching (control group); didactic plus CBL (Intervention Group 1); or didactic plus SE (Intervention Group 2). The educational curriculum used the topical focus of triage processes during disaster situations. Cases for the educational intervention sessions were scripted, identical between modalities, and employed structured debriefing. Trained live actors were used for SEs. After primary assessment, the groups underwent crossover to take part in the alternative educational modality and were re-assessed. Two standardized multiple-choice question batteries, encompassing key core content, were used for assessments. A sample size of 48 participants was calculated to detect a ≥20% change in mean knowledge score (α=0.05; power=80%). Robustness of randomization was evaluated using X2, anova, and t-tests. Mean knowledge attainment scores were compared using one- and two-sample t-tests for intergroup and intragroup analyses, respectively.
ResultsAmong 60 enrolled participants, 88.3% completed follow-up. No significant differences in participant characteristics existed between randomization arms. Mean baseline knowledge score in the control group was 43.8% (standard deviation=11.0%). Case-based learning training resulted in a significant increase in relative knowledge scores at 20.8% (P=0.003) and 10.3% (P=.033) in intergroup and intragroup analyses, respectively. As compared to control, SEs did not significantly alter knowledge attainment scores with an average score increase of 6.6% (P=.396). In crossover intra-arm analysis, SEs were found to result in a 26.0% decrement in mean assessment score (P < .001).
ConclusionsAmong nursing trainees assessed in this RCT, the CBL modality was superior to SEs in short-term disaster preparedness educational translation. Simulation exercises resulted in no detectable improvement in knowledge attainment in this population, suggesting that CBL may be utilized preferentially for adult learners in similar disaster training settings.
,Aluisio AR ,Daniel P ,Grock A ,Freedman J ,Singh A ,Papanagnou D .Arquilla B Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial . Prehosp Disaster Med.2016 ;31 (5 ):516 –523 .
Epidemiology of Traumatic Injuries in the Northeast Region of Haiti: A Cross-sectional Study
- Adam R. Aluisio, Annelies De Wulf, Ambert Louis, Christina Bloem
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- Journal:
- Prehospital and Disaster Medicine / Volume 30 / Issue 6 / December 2015
- Published online by Cambridge University Press:
- 09 November 2015, pp. 599-605
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- December 2015
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Introduction
More than 90% of traumatic morbidity and mortality occurs in low- and middle-income countries (LMIC). Haiti is the poorest country in the Western Hemisphere and lacks contemporary statistics on the epidemiology of traumatic injuries. This study aimed to characterize the burden of traumatic injuries among emergency department patients in the Northeast region of Haiti.
MethodsData were collected from the emergency departments of all public hospitals in the Northeast region of Haiti, which included the Fort Liberté, Ouanaminthe, and Trou du Nord sites. All patients presenting for emergent care of traumatic injuries were included. Data were obtained via review of emergency department registries and patient records from October 1, 2013 through November 30, 2013. Data on demographics, mechanisms of trauma, and anatomical regions of injury were gathered using a standardized tool and analyzed using descriptive statistics. Temporal analysis of injury frequency was explored using regression modeling.
ResultsData from 383 patient encounters were accrued. Ouanaminthe Hospital treated the majority of emergent injuries (59.3%), followed by Fort Liberté (30.3%) and Trou du Nord (10.4%). The median age in years was 23 with 23.1% of patients being less than 15 years of age. Road traffic accidents (RTAs) and interpersonal violence accounted for 65.8% and 30.1% of all traumatic mechanisms, respectively. Extremity trauma was the most frequently observed anatomical region of injury (38.9%), followed by head and neck (30.3%) and facial (19.1%) injuries. Trauma due to RTA resulted in a single injury (83.8%) to either an extremity or the head and neck regions most frequently. A minority of patients had medical record documentation (37.9%). Blood pressure, respiratory rate, and mental status were documented in 19.3%, 4.1%, and 0.0% of records, respectively. There were 6.3 injuries/day during the data collection period with no correlation between the frequency of emergent trauma cases and day of the week (R^2=0.01).
ConclusionsTraumatic injuries are a common emergent presentation in the Northeast region of Haiti with characteristics similar to other LMIC. Documentation and associated data to adequately characterize the burden of disease in this region are lacking. Road traffic accidents are the predominate mechanism of injury, suggesting that interventions addressing prevention and treatment of this common occurrence may provide public health benefits in this setting.
,Aluisio AR ,De Wulf A ,Louis A .Bloem C Epidemiology of Traumatic Injuries in the Northeast Region of Haiti: A Cross-sectional Study . Prehosp Disaster Med.2015 ;30 (6 ):599 –605 .
Emergency Care Capabilities in North East Haiti: A Cross-sectional Observational Study
- Annelies De Wulf, Adam R. Aluisio, Dana Muhlfelder, Christina Bloem
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- Journal:
- Prehospital and Disaster Medicine / Volume 30 / Issue 6 / December 2015
- Published online by Cambridge University Press:
- 21 October 2015, pp. 553-559
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- December 2015
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Introduction
The North East Department is a resource-limited region of Haiti. Health care is provided by hospitals and community clinics, with no formal Emergency Medical System and undefined emergency services. As a paucity of information exists on available emergency services in the North East Department of Haiti, the objective of this study was to assess systematically the existing emergency care resources in the region.
MethodsThis cross-sectional observational study was carried out at all Ministry of Public Health and Population (MSPP)-affiliated hospitals in the North East Department and all clinics within the Fort Liberté district. A modified version of the World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care and Generic Essential Emergency Equipment Lists were completed for each facility.
ResultsThree MSPP hospitals and five clinics were assessed. Among hospitals, all had a designated emergency ward with 24 hour staffing by a medical doctor. All hospitals had electricity with backup generators and access to running water; however, none had potable water. All hospitals had x-ray and ultrasound capabilities. No computed tomography scanners existed in the region. Invasive airway equipment and associated medications were not present consistently in the hospitals’ emergency care areas, but they were available in the operating rooms. Pulse oximetry was unavailable uniformly. One hospital had intermittently functioning defibrillation equipment, and two hospitals had epinephrine. Basic supplies for managing obstetrical and traumatic emergencies were available at all hospitals. Surgical services were accessible at two hospitals. No critical care services were available in the region. Clinics varied widely in terms of equipment availability. They uniformly had limited emergency medical equipment. The clinics also had inconsistent access to basic assessment tools (sphygmomanometers 20% and stethoscopes 60%). A protocol for transferring patients requiring a higher level of care was present in most (80%) clinics and one of the hospitals. However, no facility had a written protocol for transferring patients to other facilities. One hospital reported intermittent access to an ambulance for transfers.
ConclusionsDeficits in the supply of emergency equipment and limited protocols for inter-facility transfers exist in North East Department of Haiti. These essential areas represent appropriate targets for interventions aimed at improving access to emergency care within the North East region of Haiti.
,De Wulf A ,Aluisio AR ,Muhlfelder D .Bloem C Emergency Care Capabilities in North East Haiti: A Cross-sectional Observational Study . Prehosp Disaster Med.2015 ;30 (6 ):553 –559 .
Prehospital Characteristics in the North East Department of Haiti: A Cross-sectional Study from a Low-income Setting Without Prehospital Systems
- Adam R. Aluisio, Robert Gore, Isnelle Decome, Annelies De Wulf, Christina Bloem
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- Journal:
- Prehospital and Disaster Medicine / Volume 29 / Issue 3 / June 2014
- Published online by Cambridge University Press:
- 12 May 2014, pp. 230-236
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- June 2014
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Introduction
Although prehospital care is recognized as key in health systems development, it has been largely neglected in Haiti. The North East Department is one of the poorest areas of Haiti, and is a region where no data on out-of-hospital health care exists. This research assessed prehospital characteristics in the North East Department with the aim of providing baseline data to inform prehospital systems development.
MethodsIn this observational study, data were collected from patients presenting at the Fort Liberté Hospital, the public regional referral health center in the North East Department. Data were accrued from April 2, 2012 through June 5, 2012. All patients accessing acute care at the hospital were eligible for enrollment. After obtaining consent, data on demographics, health needs, and prehospital information were gathered via a standardized questionnaire administered by hospital staff trained in study protocols.
ResultsData were collected from 441 patient visits. The median age was 24 years, with 62% of the population being female. Medical complaints comprised 75% of visits, with fever and gastrointestinal complaints being the most common reasons for presentation. Traumatic injuries accounted for 25% of encounters, with an equal distribution of blunt and penetrating events. Extremity injuries were the most common traumatic subclassification. The majority of patients (67.2%) were transported by motorcycle taxi and paid transport fees. Trauma patients were more likely to be transported without charge (OR = 9.10; 95% CI, 2.19-37.76; P < .001). Medical patients were most commonly brought from home (78.5%) and trauma patients from a road/street setting (42.9%). Median time to presentation was 240 minutes (IQR = 120-500) and 65 minutes (IQR = 30-150) for medical and trauma complaints, respectively (P < .001). Eleven percent of patients reported receiving care prior to arrival. As compared with medical patients, trauma victims were less likely to have received prehospital care.
ConclusionsAssessing prehospital care in this low-income setting that lacks surveillance systems was feasible and required minimal resources. Motorcycle taxi drivers function as the primary emergency transport mechanism and may represent an access point for prehospital interventions in the North East Department of Haiti. Out-of-hospital care is nearly nonexistent in the region and its development has the potential to yield public health benefits.
. ,Aluisio AR ,Gore R ,Decome I ,De Wulf A .Bloem C Prehospital Characteristics in the North East Department of Haiti: A Cross-sectional Study from a Low-income Setting Without Prehospital Systems . Prehosp Disaster Med.2014 ;29 (3 ):1 -7