BackgroundOut-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery.MethodsWe performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary.ResultsA total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation.ConclusionsPolicy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

The Broselow tape and APLS estimation methods are most accurate in estimating weight in the Western Cape paediatric population, even though they have a small tendency to underestimate weight. Clinicians need to bear in mind that none of the formulae are infallible and constant reassessment and clinical judgement should be used, as well as a measured weight as soon as possible in an emergency situation.

PurposeCritically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.MethodsA year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.ResultsThe study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.ConclusionsThe study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

Clear trends are seen for patient demographics and temporal attendance patterns which are important for resource allocation and planning. Many low-acuity patients, largely non-referred, are being seen in the EC and should be managed by primary health care level staff outside the EC.

The care and support of older people residing in long-term care facilities during the COVID-19 pandemic has created new and unanticipated uncertainties for staff. In this short report, we present our analyses of the uncertainties of care home managers and staff expressed in a self-formed closed WhatsApp™ discussion group during the first stages of the pandemic in the UK. We categorised their wide-ranging questions to understand what information would address these uncertainties and provide support. We have been able to demonstrate that almost one-third of these uncertainties could have been tackled immediately through timely, responsive and unambiguous fact-based guidance. The other uncertainties require appraisal, synthesis and summary of existing evidence, commissioning or provision of a sector- informed research agenda for the medium- to longer-term. The questions represent wider internationally relevant care home pandemic related uncertainties.