Clinical Outcomes Following the Implementation of a Novel One-Year Training Program in Emergency Medicine in Karachi, Pakistan

Overview

Journal Ann Glob Health

Publisher Ubiquity Press

Specialties General Medicine
Public Health

Date 2023 Feb 1

PMID 36721434

Authors

Syed Ghazanfar Saleem

Saima Ali

Adeel Khatri

Sama Mukhtar

Wasfa Farooq

Quratulain Maroof

Muhammad Imran Jamal

Tariq Aziz

Kaniz Farwa Haider

Farah Z Dadabhoy

Megan M Rybarczyk

Affiliations

Soon will be listed here.

Abstract

Background: Most Emergency Departments (EDs) in low- and middle-income countries (LMICs), particularly in Pakistan, are staffed by physicians not formally trained in Emergency Medicine (EM). As of January 2022, there were only 13 residency training programs in EM throughout all of Pakistan. Therefore, an intermediate solution-a one-year training program in EM-was developed to build capacity.

Objective: To determine the impact of a novel training program in EM on clinical metrics and outcomes.

Methods: The first cohort of a novel, one-year training program-the Certification Program in Emergency Medicine (CPEM)-completed the program in June 2019. The program consisted of two arms: CPEM-Clinical (CPEM-C), which included physicians from the Indus Hospital and Health Network (IHHN) ED; and CPEM-Didactic (CPEM-D), which included physicians from EDs across Karachi. Both groups participated in weekly conferences, such as didactics, small group discussions, workshops, and journal clubs. CPEM-C learners also received clinical mentorship from local and international faculty. Mortality, length of stay (LOS), and time-to-evaluation, as well as metrics in four key areas-patients at risk for cardiovascular disease/acute coronary syndrome, sepsis, respiratory illness, and intra-abdominal trauma-were assessed before and after the initial cohort at IHHN and compared with other groups in IHHN.

Findings And Conclusions: More than 125,000 patients were seen from July to December 2017 (pre-CPEM) and July to December 2019 (post-CPEM). Overall, there were significant improvements in all clinical metrics and outcomes, with the exception of LOS and time-to-evaluation, and a trend toward improved mortality. In comparing CPEM graduates to other groups in IHHN ED, most metrics and outcomes significantly improved or trended toward improvement, including mortality. Implementation of a medium-duration, intensive EM training program can help improve patient care and the development of EM as a new specialty in lower-resource settings.

Citing Articles

Towards Establishing a National Perioperative Quality Improvement Network in LMICs: Implementation Experiences From Ethiopia.

Kifle F, Iverson K, Belay E, Teko E, Dawit A, Deneke A Ann Surg Open. 2024; 5(3):e480.

PMID: 39310363 PMC: 11415095. DOI: 10.1097/AS9.0000000000000480.

References

Lindsay P, Schull M, Bronskill S, Anderson G . The development of indicators to measure the quality of clinical care in emergency departments following a modified-delphi approach. Acad Emerg Med. 2002; 9(11):1131-9. DOI: 10.1111/j.1553-2712.2002.tb01567.x. View

Aluisio A, Waheed S, Cameron P, Hess J, Jacob S, Kissoon N . Clinical emergency care research in low-income and middle-income countries: opportunities and challenges. BMJ Glob Health. 2019; 4(Suppl 6):e001289. PMC: 6666826. DOI: 10.1136/bmjgh-2018-001289. View

Bouzat P, Valdenaire G, Gauss T, Charbit J, Arvieux C, Balandraud P . Early management of severe abdominal trauma. Anaesth Crit Care Pain Med. 2019; 39(2):269-277. DOI: 10.1016/j.accpm.2019.12.001. View

Ahmed M, Shah M, Luby S, Wali S . Survey of surgical emergencies in a rural population in the Northern Areas of Pakistan. Trop Med Int Health. 2000; 4(12):846-57. DOI: 10.1046/j.1365-3156.1999.00490.x. View

Koch E, Lovett S, Nghiem T, Riggs R, Rech M . Shock index in the emergency department: utility and limitations. Open Access Emerg Med. 2019; 11:179-199. PMC: 6698590. DOI: 10.2147/OAEM.S178358. View

Broccoli M, Moresky R, Dixon J, Muya I, Taubman C, Wallis L . Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa. BMJ Glob Health. 2018; 3(1):e000479. PMC: 5841514. DOI: 10.1136/bmjgh-2017-000479. View

Aaronson E, Marsh R, Guha M, Schuur J, Rouhani S . Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med. 2015; 8(1):39. PMC: 4628609. DOI: 10.1186/s12245-015-0088-x. View

Li L, Georgiou A, Vecellio E, Eigenstetter A, Toouli G, Wilson R . The effect of laboratory testing on emergency department length of stay: a multihospital longitudinal study applying a cross-classified random-effect modeling approach. Acad Emerg Med. 2015; 22(1):38-46. PMC: 6680199. DOI: 10.1111/acem.12565. View

Kemmler C, Saleem S, Ali S, Samad L, Haider K, Jamal M . A 1-year training program in emergency medicine for physicians in Karachi, Pakistan: Evaluation of learner and program outcomes. AEM Educ Train. 2021; 5(3):e10625. PMC: 8241570. DOI: 10.1002/aet2.10625. View

10.

Singer M, Deutschman C, Seymour C, Shankar-Hari M, Annane D, Bauer M . The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-10. PMC: 4968574. DOI: 10.1001/jama.2016.0287. View

11.

Wright R, Ettinger S, Ganiats T, Jneid H, Philippides G, Wenger N . 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart.... J Am Coll Cardiol. 2011; 57(19):e215-367. DOI: 10.1016/j.jacc.2011.02.011. View

12.

Beattie E, Mackway-Jones K . A Delphi study to identify performance indicators for emergency medicine. Emerg Med J. 2004; 21(1):47-50. PMC: 1756339. DOI: 10.1136/emj.2003.001123. View

13.

Kobusingye O, Hyder A, Bishai D, Hicks E, Mock C, Joshipura M . Emergency medical systems in low- and middle-income countries: recommendations for action. Bull World Health Organ. 2005; 83(8):626-31. PMC: 2626309. DOI: /S0042-96862005000800017. View

14.

Roffi M, Patrono C, Collet J, Mueller C, Valgimigli M, Andreotti F . 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment.... Eur Heart J. 2015; 37(3):267-315. DOI: 10.1093/eurheartj/ehv320. View

15.

Chang C, Abujaber S, Reynolds T, Camargo Jr C, Obermeyer Z . Burden of emergency conditions and emergency care usage: new estimates from 40 countries. Emerg Med J. 2016; 33(11):794-800. PMC: 5179323. DOI: 10.1136/emermed-2016-205709. View

16.

Schuur J, Hsia R, Burstin H, Schull M, Pines J . Quality measurement in the emergency department: past and future. Health Aff (Millwood). 2013; 32(12):2129-38. DOI: 10.1377/hlthaff.2013.0730. View

17.

Jafar T, Jafary F, Jessani S, Chaturvedi N . Heart disease epidemic in Pakistan: women and men at equal risk. Am Heart J. 2005; 150(2):221-6. DOI: 10.1016/j.ahj.2004.09.025. View

18.

Moretti K, Uwamahoro D, Naganathan S, Uwamahoro C, Karim N, Nkeshimana M . Emergency medicine matters: epidemiology of medical pathology and changes in patient outcomes after implementation of a post-graduate training program at a Tertiary Teaching Hospital in Kigali, Rwanda. Int J Emerg Med. 2021; 14(1):9. PMC: 7819192. DOI: 10.1186/s12245-021-00331-2. View

19.

Zachariasse J, Seiger N, Rood P, Alves C, Freitas P, Smit F . Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS One. 2017; 12(2):e0170811. PMC: 5289484. DOI: 10.1371/journal.pone.0170811. View

20.

Marsh D, Kadir M, Husein K, Luby S, Siddiqui R, Khalid S . Adult mortality in slums of Karachi, Pakistan. J Pak Med Assoc. 2000; 50(9):300-6. View