A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered—signal functions—associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.
- emergency care systems
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Mortality-reduction programmes in sub-Saharan Africa largely focus on specific disease states or patient populations, such as pregnant women, children younger than 5 years of age or people living with HIV/AIDS. This programming is often poorly matched to the realities of delivery systems in which a large number of patients do not access health services through primary care but rather seek sporadic, symptom-driven care from the closest health facility when they are acutely unwell.1 ,2 A system that is purpose-designed for an integrated approach to the resuscitation, stabilisation and diagnosis of patients with these potentially fatal conditions can provide reductions in morbidity and mortality across all at-risk populations: acute care is such a system and includes all health system components that are leveraged to mitigate the time-dependent morbidity or mortality of sudden and unexpected illness or injury.3 Acute care includes, but is not limited to, emergency care, which focuses on delivering stabilising interventions for severe, time-sensitive conditions that if untreated rapidly progress to death or significant morbidity.4
The emergent portion of such presentations requires initial stabilisation and management by frontline providers according to rigorous syndromic recognition followed by timely, accurate diagnoses to facilitate definitive care. All severely ill patients, regardless of the disease aetiology, ultimately progress through a limited set of clinical syndromes prior to death. Evaluation of the management of this limited set of syndromes should allow assessment of the functionality of emergency care delivery. The emergency obstetrics literature has successfully accomplished this by using an obstetric-specific set of clinical syndromes—‘sentinel conditions’—to generate a framework for essential interventions for obstetric emergencies.5 These sentinel conditions are haemorrhage, sepsis, unsafe abortion, pre-eclampsia, eclampsia and prolonged obstructed labour: presentations that are both life-threatening in pregnancy and lend themselves to simple evaluation. Each obstetric sentinel condition has one or more life-saving clinical interventions associated with it, which are designated as ‘signal functions’.5 These signal functions can be used to assess a health facility's ability to manage the associated sentinel condition and, by extrapolation, determine whether there is a functional system for emergency obstetric care at that facility.
Here, we develop a similar argument for emergency care and present a consensus-based framework to facilitate the development and assessment of emergency care delivery sites.
Current state of emergency care resource-limited settings
In general, emergency care in resource-limited settings lacks a formalised structure and is poorly integrated into health system planning.2 At the most basic facility level, a single healthcare practitioner delivers emergency care to patients who come to a one-room facility. District-level facilities may or may not have a designated room or intake area for emergencies. Designated ‘emergency departments’ in regional and tertiary facilities vary widely in form and function; few of them have adopted an integrated approach to triage and stabilisation of acutely ill and injured patients. Instead, patients are often seen in order of arrival rather than acuity and may wait hours for initial care until a provider from an inpatient service arrives.6
The importance of emergency care in health systems has gained some recognition. In 2007, the World Health Assembly called for its member states to develop ‘formal, integrated emergency care systems’.7 Nascent efforts to improve access to emergency care are slowly increasing in sub-Saharan Africa: dedicated emergency care centres are being established, prehospital care systems are becoming more formally organised and the specialty of emergency medicine has gained a foothold.8–13 Several governments have recognised emergency medicine as a specialty and have established residency training programmes as an integral part of their emergency care strategy.11 ,14 ,15 Professional emergency medicine societies have been created and novel programmes are exploring task shifting as a possible solution to the lack of human resources to provide emergency care.16
These are significant and welcome steps, but a large gap still remains between the demands of daily emergencies and the integrated systems necessary to maximise patient outcomes. A common misconception is that delivery of emergency care requires significant input and allocation of resources.17 In fact, interventions that significantly decrease mortality often require few physical resources; the simple training of practitioners to recognise sentinel conditions and perform appropriate interventions with local resources can substantially reduce the risk of death.18 ,19 Mortality rates from sepsis, for example, have been shown to be greatly improved by altering practices to decrease the time between triage and initiation of appropriate treatment.20 Even in extremely low-resource settings, the time between recognition of sepsis and antibiotic administration can be decreased.21
Existing resources for assessing emergency care capacity
A critical barrier to emergency care development is the lack of consensus on the essential components of emergency care and the lack of available technical documents to guide emergency care system development. Countries with well-established emergency care systems, such as the UK and Australia, have developed system-wide assessment mechanisms appropriate for their specific context.22 ,23 However, the notable differences in disease epidemiology, facility infrastructure and data availability in resource-limited environments severely limit the applicability of these tools to emergency care systems in other settings.
Before assessing the effectiveness of the whole system (especially when the system is only just beginning to be formally established), a key step is defining the capabilities of the individual facilities providing care. To date, there is no standard reference framework to apply to facility-level emergency care of undifferentiated acutely ill patients. However, quantitative tools for certain disease-specific emergencies have been developed. In 2004, the WHO released the Guidelines for Essential Trauma Care to address the increasing global burden of death and disability from injury.24 Those guidelines recommend essential trauma care services that every country should provide and enumerate the human and physical resources needed to provide the recommended services. To promote implementation of these guidelines, two assessment tools were developed.25 The Full Essential Trauma Care Checklists designates whether each item in the Guidelines is essential, desirable or possibly required at three levels of healthcare facilities. The Brief Essential Trauma Care Checklist is designed to be completed in 1 hour and contains only the ‘most essential, highly critical and cost-effective items’. Both of these checklists include knowledge and skills in addition to equipment and supplies needed for trauma care. While these checklists have been used in many African countries, they do not cover the full spectrum of emergency presentations.26–29
The WHO Integrated Management for Emergency and Essential Surgical Care toolkit is intended to reduce morbidity and mortality from surgically managed disease across a number of specialties (obstetrics/gynaecology, acute surgical care and trauma care).30 The central component is a comprehensive questionnaire that assesses a given healthcare facility's surgical capacity and asks questions related to available interventions, equipment, infrastructure and human resources.31 ,32 The toolkit includes a list of suggested essential items and has been implemented in several African countries.33–36 Studies on its use report the ability to detect deficiencies in surgical care infrastructure, resources and interventions but do not delineate the full spectrum of emergency care.37
The WHO's Monitoring Emergency Obstetric Care handbook took a novel approach to facility assessment: the use of a systematic evaluation based primarily on adequacy of services, oriented around ‘signal functions’.5 Signal functions are key clinical capacities that indicate operational care delivery; signal functions encompass elements of knowledge, skills, infrastructure and supplies. For example, successful administration of parenteral antibiotics implies provider capacity to evaluate the need for antibiotics; the skill to establish intravenous access; and the availability of the intravenous tubing, catheters and medication. If any of these components are absent, the function cannot be executed, flagging a deficiency for further review. In this way, signal functions limit the number of items that need to be assessed without losing sensitivity to detect system failure at a facility level. This concept is particularly translatable to emergency conditions, in which a concatenation of events must occur to produce the desired function.
AFEM consensus-based development of emergency care signal functions
The African Federation for Emergency Medicine (AFEM), formed in 2009, is an umbrella organisation for African national emergency care societies and leaders in the region. In total, 135 experts in African emergency care, public health, medical education and research attended the 1 day 2013 AFEM Consensus Conference. Participants included physicians, mid-level providers, nurses, first responders and government administrators, and represented 18 African and 14 non-African countries. The 2013 AFEM Consensus Conference provided rare access to collective knowledge and experience of emergency care providers from clinical settings across sub-Saharan Africa.
The goals of the consensus process were to (1) define a core set of sentinel conditions, (2) derive context-appropriate emergency care signal functions from sentinel conditions and (3) use these definitions to create the foundation for a facility-based assessment framework. For each of the conference objectives, consensus was reached via discussion and written contributions. A final session was held for presentation, discussion and ratification. Further refinement was achieved by personal and written communications.
While emergency care covers a wide breadth of medicine, the essential differentiating feature is its focus on immediate life threats and time-sensitive interventions. Efficacy in emergency care may therefore be measured by how well the system addresses the pathophysiological events immediate or commonly proximate to death. The working group used six sentinel conditions as an initial conceptual framework. These conditions were partially informed by the WHO Integrated Management of Adult and Adolescent Illness38 and then developed during pre-conference planning by the core organising group. Although there are many determinants of disease severity, these six sentinel emergency conditions represent common syndromes that occur proximate to death (table 1): (1) respiratory failure, (2) shock states, (3) altered mental status, (4) dangerous fever, (5) severe pain and (6) trauma.38 The working group agreed that the central function of an emergency care system, at any resource level, is to recognise and manage these sentinel emergency syndromes.
Generating signal functions from sentinel conditions
The signal functions required to respond to sentinel conditions were assigned by the workgroup (table 2). Recurrent signal functions were listed in italics after the first mention to enable provision of a comprehensive list. Signal functions were then assigned by consensus to facility level (table 2). Analogous to the trauma hospital designations that have emerged in the USA, the facility-level designation was defined by the functional level of emergency care delivered at a given facility (see online supplementary addendum 1–3) rather than by traditional health ministry classifications (such as district or regional).39 The specific labels of facility designation—basic, intermediate and advanced—were chosen to carry consistent meanings across cultural, political and regional differences and provide an objective classification of the services delivered. They are presented as categories for discussion and will map differently onto different country healthcare systems.
The basic level was defined as a healthcare institution with the ability to provide first response and stabilisation of emergency patients, such as a health outpost. Although these facilities usually have scant resources, they are often the most accessible. The main resources they offer are the knowledge and skills of their staff. The intermediate level of care was defined as encompassing the knowledge and skills of the basic level in a facility that has sufficient resources to attain intravenous access and establish a definitive airway, though not necessarily the capacity to provide mechanical ventilation. Advanced facilities are those with staff members who have robust knowledge and skills as well as the resources to provide comprehensive emergency services to address sentinel conditions.
Facility infrastructure requirements based on facility designation were developed (table 3). Medical products and technologies were assigned by the workgroup according to the desired signal functions for each level of facility (table 4). A detailed analysis of the medications necessary to execute signal functions was beyond the scope of the consensus meeting, though they can be extracted from national formularies and WHO essential medication lists.40
Emergency signal functions do not include every service that is required, but indicate consensus-based designation of a minimum level of care that should be available, and this framework can be used for the assessment and monitoring of facility-based emergency care. Each country should determine its own stratification of the tiers of emergency care that are needed, based on the local epidemiology of acute disease patterns. The consensus-identified infrastructure and equipment necessary to perform each signal function, while not comprehensive, can be used for bench-marking and enabling data-driven decisions by organisations wishing to establish or improve their facility-based emergency care delivery.
Emergency health workforces vary in skills and availability among regions, so the framework proposed in this article gives priority to interventions rather than the level of provider required to perform them. The cadre of health workers to be assigned to a basic, intermediate or advanced facility should be determined by local certification bodies, taking into consideration national health priorities, training capacity and the burden of acute disease.
All healthcare facilities will be faced with acutely ill patients, whether they are prepared or not. Real solutions to the challenge of emergency care provision are urgently needed in the region to avoid excess death and disability. The 2013 AFEM consensus conference findings provide a foundation for facility capacity assessment in nascent emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery. Integration of effective emergency care into health service delivery will ensure timely treatment when patients need it most and further development of health systems capable of meeting population needs.
Through a consensus process, we defined sentinel conditions for emergency care and a set of accompanying signal functions. These findings are currently being developed into a simple assessment tool for emergency health systems. Further validation and refinement of these concepts and the resultant tool will augment assessment and strategic planning for countries seeking to develop their essential emergency care capacity.
The AFEM Systems Workgroup was comprised of 40 participants from 15 countries, including Cameroon, Egypt, Ethiopia, Ghana, Kenya, Malawi, Namibia, South Africa, Sudan, Tanzania, Uganda and Zambia. AFEM would like to thank the following members of the AFEM Systems Workgroup for their contributions to the findings described in this paper: Abdelmonim Abdelrahman, Chanceline Bilolinga, Feggie Bodole, Conrad Buckle, Lochelle Chetty, Charmaine Cunningham, Mohammed Dalwai, Carianne Deelstra, Ahmed Eid, Jacques Goosen, Rachel Hangula, Trish Henwood, Tanya Heyns, Jon Mark Hirshon, Peter Hodkinson, Bonaventure Hollong, Sandy Inglis, Muhumpu Kafwamfwa, Valerie Krym, Kundai Mapanga, Shingai Mapanga, Joseph Novik, Margaret Salmon, Angelina Sepeku, DeVilliers Smit, Melanie Stander, Jim Svenson, Benjamin Wachira, Robert Wangoda and Ellen Weber. The authors thank Linda J Kesselring for her valuable assistance. Ellen Weber recused herself from deliberations on this manuscript.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online supplement
Twitter Follow Janis Tupesis at @janistupesis and Emilie J.B. Calvello at @ejbcalvello and the African Federation of Emergency Medicine at @InfoAFEM.
Contributors EJBC designed the conceptual framework and structure, facilitated the consensus process, analysed the data collection, drafted and revised the paper. AGT facilitated the consensus process, analysed the data collection and revised the manuscript. MCB and APS collected the data, cleaned and analysed the data and drafted and revised the paper. PB, ST, JPT and AEM participated in the consensus conference and revised the manuscript. LW and TR gave inputs into the conceptual framework and revised the manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.