Maxwell Osei-Ampofo

Clinical and Translational Research in Global Health and Emergency Care: A Research Agenda

As policy-makers increasingly recognize emergency care to be a global health priority, the need for high-quality clinical and translational research in this area continues to grow. As part of the proceedings of the 2013 Academic Emergency Medicine consensus conference, this article discusses the importance of: 1) including clinical and translational research in the initial emergency care development plan, 2) defining the burden of acute disease and the barriers to conducting research in resource-limited settings, 3) assessing the appropriateness and effectiveness of local and global acute care guidelines within the local context, 4) studying the local research infrastructure needs to understand the best methods to build a sustainable research infrastructure, and 5) studying the long-term effects of clinical research programs on health care systems.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience

BACKGROUND Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available. OBJECTIVES To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC. METHODS We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session. RESULTS The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE. CONCLUSION A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.

Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial

To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource‐limited setting.

Skill and knowledge retention after training in cardiopulmonary ultrasound in Ghana: an impact assessment of bedside ultrasound training in a resource-limited setting

Objective Brief training courses in bedside ultrasound are commonly done by visiting faculty in low-income and middle-income countries, and positive short-term effects have been reported. Long-term outcomes are poorly understood. We held a training course on a cardiopulmonary ultrasound (CPUS) protocol over two separate 10-day periods in 2016. In 2017, 9–11 months after the initial training, we assessed skill and knowledge retention as well as perceived impact on local practice. Methods A written test using six clinical vignettes and an observed structured clinical examination were used to assess theoretical knowledge and practical skills. Additionally, in-person interviews and a written survey were completed with the physicians who had participated in the initial training. Results All 20 participants passed the written and clinical examination. The median follow-up test score was 10 out of 12, compared with a median score of 12 on a test completed immediately after the initial training. Physicians identified the ability to narrow their differential diagnosis and to initiate critical interventions earlier than without ultrasound as a key benefit of the CPUS training. They rated the cardiac, abdominal and inferior vena cava components of the CPUS protocol as most relevant to their everyday practice. Conclusion Long-term ultrasound knowledge and skill retention was high after a brief and intensive training intervention at an academic tertiary hospital in Ghana. Clinicians reported improvements in patient care and local practice patterns.

263: ULTRASOUND-GUIDED RESUSCITATION OF CRITICALLY ILL PATIENTS IN A LOW-RESOURCE SETTING

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: The impact of cardiopulmonary ultrasonography (CPUS) on diagnostic accuracy and early clinical care of critically ill patients in a resource-limited environment is largely unknown. We studied the use of CPUS in patients presenting to the emergency department (ED) at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Methods: Select emergency physicians (EPs) underwent training in CPUS. Adult non-trauma patients presenting to the ED were enrolled if they exhibited signs or symptoms of hypoperfusion or hypoxia. Patients either received standard care plus CPUS-guided diagnosis and treatment during their initial resuscitation, or standard care alone depending on whether their treating EP had been trained in CPUS. The primary outcome was diagnostic accuracy which was assessed by comparing the treating EPs most likely diagnosis after the initial assessment with the final ED diagnosis. The ED diagnosis was obtained through blinded chart review performed by two board certified emergency physicians with experience working in resource-limited environments. Secondary outcomes were 24-hour mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. A power calculation based on local historical data and previous diagnostic accuracy studies was completed, and we planned on enrolling 180 patients. Results: The target sample size was met after 6 months, with 90 patients each in the intervention and control group. Diagnostic accuracy was 71.9% for patients in the intervention group versus 57.1% in the control group (p = 0.042). This effect was particularly pronounced for patients with a “cardiac” diagnosis (94.7% vs. 40.0%, p = 0.003) and those with a predicted mortality of 2550% as estimated per the Mortality Probability Model II (84.6% vs. 36.8%, p = 0.001). There was no significant difference between the two groups in terms of 24-hour mortality or use of IV fluids, diuretics, vasopressors, or bronchodilators. Conclusions: CPUS improves the accuracy of physicians’ initial diagnoses of critically ill patients in low-resource environment.

Respiratory failure requiring mechanical ventilation in critically ill adults in Ghana: A prospective observational study

Introduction Respiratory failure is commonly seen in African emergency centres and intensive care units, but little is known about the need for intubation and mechanical ventilation. Methods From April to October 2017, we recorded the number of patients intubated and ventilated in the emergency centre and intensive care unit at Komfo Anokye Teaching Hospital in Kumasi, Ghana on a daily basis. We assessed patients for presence of acute respiratory distress syndrome (ARDS) using the Kigali Modification of the Berlin ARDS criteria. ARDS patients were re-assessed daily. Results During the study period, 102 patients were intubated, of which 82 were assessed by the study team. The remaining 20 patients died before they could be assessed. Two (2.4%) patients were identified as having ARDS, and both died. Neither was treated with prone positioning or chemical paralysis. It is possible that many of the patients who died before an assessment suffered from ARDS, considering its associated high mortality, and thus the true incidence of ARDS may have been higher. Conclusion Respiratory failure requiring intubation and mechanical ventilation is common in patients presenting to the emergency centre or intensive care unit at an academic tertiary care centre in Ghana. The true incidence of ARDS was likely underestimated by our study.

Injury patterns and health outcomes among pregnant women seeking emergency medical care in Kumasi, Ghana: challenges and opportunities to improve care

Introduction In high-income countries, injury is the most common cause of non-obstetric death among pregnant women. However, the injury risk during pregnancy has not been well characterized for many developing countries including Ghana. Our study described maternal and fetal outcomes after injury at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and identified associations between the prevalence of poor outcomes and maternal risk factors. Methods We conducted a cross-sectional study to identify pregnant women treated for injury over a 12-month period at KATH in Kumasi, Ghana. Descriptive statistics were used to characterize the population. We identified the association between poor outcomes and maternal risk factors using multivariable Poisson regression. Results There were 134 women with documented pregnancy who sought emergency care for injury (1.1% of all injured women). The leading injury mechanisms were motor vehicle collision (23%), poisoning (21%), and fall (19%). Assault was implicated in 3% of the injuries. Eleven women (8%) died from their injuries. The prevalence of poor fetal outcomes: fetal death, distress or premature birth, was high (61.9%). One in four infants was delivered prematurely following maternal injury. After adjusting for maternal and injury characteristics, poor fetal outcomes were associated with pedestrian injury (adjusted prevalence ratio (aPR) 2.5, 95% CI 1.5–4.6), and injury to the thoraco-abdominal region (aPR 2.1, 95% CI 1.4–3.3). Conclusions Injury is an important cause of maternal morbidity and poor fetal outcomes. Poisoning, often in an attempt to terminate pregnancy, was a common occurrence among pregnant women treated for injury in Kumasi. Future work should address modifiable risk factors related to traffic safety, prevention of intimate partner violence, and prevention of unintended pregnancies.