Management of Acute Surgical Patients

by Non-Physician Emergency Care

Practitioners in Rural Uganda
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
http://globalemergencycare.org/
 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

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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

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 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
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 Emergency Care System
Community lay-person first response

Ambulance service response

 (if available)

Acute care - Emergency Department

Definitive care - surgical, medical 5

 Bystand Right Person, Right Place, Right Time
er First Emergency Chain of Survival Rehabilitation
Aid

Emergency
Service Intensive Care
Dispatch

Field based
Early
Critical
Specialist
Intervention
Intervention
Transport to
Appropriate Rapid
Unit Early Diagnosis
Resuscitation

Field Based Care Facility Based Care Definitive Care6

Why Support Emergency Care?

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 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
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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

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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

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 GECC Initial Site
• Karoli Lwanga Hospital

• 150 bed hospital in

Rukungiri district, Southwest
rural Uganda
• 6 bed Emergency
Department
• 300-700 patients per month

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 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
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 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

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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

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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
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 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%

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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)

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 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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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.
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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
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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.org

http://globalemergencycare.org/
Twitter: @globalemergcare
Thank you for your time!
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