Systematic review Emergency care in 59 low- and middle-income countries: a systematic review Ziad Obermeyer,a Samer Abujaber,b Maggie Makar,b Samantha Stoll,c Stephanie R Kayden,b Lee A Wallisd & Teri A Reynoldse on behalf of the Acute Care Development Consortium Objective To conduct a systematic review of emergency care in low- and middle-income countries (LMICs). Methods We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards. Findings We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. Conclusion Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings. Introduction Ebola virus disease,1 cholera,2 armed conflict3 and natural disasters4 have recently strained systems for the provision of emergency care in low- and middle-income countries (LMICs). Expert groups have voiced concern about these systems’ critical lack of surge capacity and resilience.5 Even in non-crisis situations, small surveys6,7 and anecdotal accounts8 hint at high volumes of critically-ill patients seeking emergency care in LMICs. This makes emergency care different from other health settings – including primary care – where doctors typically see only 8–10 ambulatory patients per day.9 In high-income countries, decades of advances in clinical science and care delivery have dramatically improved process efficiency and patient outcomes for a range of acute conditions.10–16 Despite increasingly urgent calls to apply lessons learnt in high-income countries to LMICs,17–19 a lack of data from the field has made it difficult to convince policy-makers to make major new investments in emergency care. Measuring the state of emergency care in LMICs is challenging, because care is delivered through a heterogeneous network of facilities and medical records are often incomplete, even for basic information such as patient identity and diagnosis.19–21 Because of these challenges, studies of emergency care in LMICs have been limited to small, ad hoc efforts, in individual facilities, that were focused on individual acute diseases and conditions.22–28 We systematically reviewed all available evi- dence on emergency care delivery to guide future research on – and improvements of – emergency health systems in LMICs. Methods Systematic search We did a systematic review (PROSPERO: CRD42014007617) – following PRISMA guidelines29 – to identify quantitative data on the delivery of emergency care to an undifferentiated patient population in all LMICs categorized as such in 2013.30 To increase capture, we also included the names of the autonomous or semi-autonomous geographical areas recognized by the World Bank30 and then disaggregated any relevant data obtained for such areas. For each country or subregion, we searched PubMed, CINAHL and World Health Organization (WHO) regional indices,31 using “emerg*” plus the country or area name as the search term. We wished to identify studies of emergency care, irrespective of location, patient complaint or provider specialty. We performed similar searches in Google Scholar but only searched within article titles. We also identified nonindexed journals that regularly published manuscripts on emergency care (available from the corresponding author) and screened every article in every issue of these journals manually. Searches were conducted between 12 August 2013 and 30 May 2014. a Department of Emergency Medicine, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States of America (USA). b Brigham and Women’s Hospital, Boston, USA. c Harvard Affiliated Emergency Medicine Residency Program, Boston, USA. d University of Cape Town, Cape Town, South Africa. e University of California at San Francisco, San Francisco, USA. Correspondence to Ziad Obermeyer (email: zobermeyer@partners.org). (Submitted: 5 October 2014 – Revised version received: 31 March 2015 – Accepted: 8 April 2015 – Published online: 26 May 2015 ) Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 577 Systematic reviews Emergency care in low- and middle-income countries Ziad Obermeyer et al. We screened reports based on their titles and abstracts in English or French. The full-text potentially relevant articles were retrieved, irrespective of language or date of publication. Since the purpose of our review was to synthesize recent evidence on emergency care, the findings summarized below relate only to data published after 1989. A summary of our observations on data that were published before 1990 is available from the corresponding author. We retained studies describing the delivery of any emergency care in a health facility to adult or paediatric patients, irrespective of the presenting complaint or condition. For each retained article, we conducted backward and forward reference searches: we screened the references cited and, using Google Scholar, we also identified and screened publications that cited the article. We excluded studies that focused on specific conditions or subsets of emergency patients unless they also provided data on the overall population or facility. We also excluded studies that aggregated data from multiple facilities and general descriptions of the state of emergency care in a country. Despite the assistance of trained medical librarians, the full texts of some potentially relevant manuscripts could not be traced. In these cases, we used data from related abstracts or posters, when available. Unpublished data We presented the study protocol and early results at the 2013 African Federation for Emergency Medicine consensus conference. We made use of this presentation and our professional networks to request relevant unpublished data from clinicians in LMICs. Some clinicians, researchers and authors were not authorized to release data that allowed the study health facility or facilities to be identified. In these cases, we identified facilities only by their locations and ownership – i.e. academic, non-profit or for-profit. Data extraction We extracted data on the characteristics of each study facility: country, urban or rural setting, bed count, annual patient volume, ownership and highest level of provider training. We considered a provider to be an emergency physician if reference was made to specialty postgraduate training, board certifica- tion or practice within an independent department of emergency medicine. We recorded details of the study population – i.e. age, sex, number of subjects included in analysis, number who arrived by ambulance – the sampling method and key patient outcomes. The latter included the inpatient admission and mortality within the emergency department, the percentages of patients recorded as brought in dead, or dead on arrival, and the length of time each patient stayed in the emergency department. We created a database containing aggregated study data. When multiple publications described a single facility, we merged them to create a single record that, for each variable of interest, contained the most recently published data available. We stratified facilities using World Bank regions30 and considered separately those facilities that only served paediatric populations. If data from a single facility were available disaggregated by age group, we summarized quantitative metrics for adult and paediatric patients separately. Full lists of the included studies and the data extracted and a full description of the study protocol are available from the corresponding author. Descriptive analysis We calculated summary statistics for all relevant metrics that were reported consistently across studies: bed count, annual patient volume, admission and mortality within the emergency department. We made an a priori decision not to perform a formal meta-analysis. Instead, our systematic analysis was meant to capture the distribution of metrics across populations – e.g. adult versus paediatric – and World Bank regions – e.g. Africa versus Asia – as well as global patterns. We thus present means – or medians with interquartile ranges (IQR) – disaggregated by country or region, as appropriate. Statistical analyses were performed using Stata/MP (StataCorp. LP, College Station, United States of America). Results Fig. 1 shows the results of our literature search. Of the 195 relevant published studies identified (Table 1; available at: http://www.who.int/bulletin/vol�umes/93/14/07-148338), 170 (87%) were descriptive reports on hospital- based emergency departments whereas the other 25 (13%) described the impact of an intervention. We obtained relevant unpublished data on a further 16 facilities. After combining multiple reports from the same facility and separating paediatric and adult data – for the three facilities with disaggregated data – we had data on 192 individual facilities in 59 countries. Of the 192 facilities, 107 (56%) were academically affiliated, 11 (6%) were in rural areas and 36 (19%) served paediatric patients exclusively; in the remaining 38, facility type could not be identified. Further information on the health facilities is available from the corresponding author. Table 2 presents the key metrics for the facilities. Median mortality within the emergency departments – of the 65 facilities that reported the relevant data – was 1.8% overall and higher in the 19 paediatric facilities (4.8%) than in the 46 adult or general facilities (0.7%). Across World Bank regions that we investigated, mortality was highest in sub-Saharan Africa (3.4%; IQR: 0.5–6.3%; n = 44), especially in east, central or west Africa (4.8%; IQR: 3.3–8.4%; n = 30). Paediatric facilities in sub-Saharan Africa had a median mortality of 5.1% (IQR: 3.5–11.1%; n = 15). Mortality in emergency facilities was also high in Latin America. Two facilities in Brazil were major contributors to this high rate, with mortality of 7.4%32 and 3.9%.33 These centres also reported long inpatient stays: one facility reported a median length of stay of three days,32 whereas the other reported that 21% of patients stayed in the emergency department for more than five days.33 Lengths of stay were only reported for 15 facilities and for these, the median value was 7.7 hours (IQR: 3.3–40.8). As mortality data were only available for nine of these 15 facilities, it was not possible to formally investigate the relationship between length of stay and mortality. The five sub-Saharan African facilities that recorded length of stay reported a median stay of 17 hours (IQR: 16.9–18.0). Additional data comparing mortality, patient volumes and admission are available from the corresponding author. Median annual patient volume was 30 021 (IQR: 10 296–60 000) among 173 facilities reporting these data. Volume was lower in the nine rural facilities (16 468; IQR: 3429–44 395) than in the 164 urban ones (31 000; 578 Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 Ziad Obermeyer et al. Systematic reviews Emergency care in low- and middle-income countries Fig. 1. Flowchart for the selection of records on the delivery of emergency care in low- and middle-income countries PubMed search: ‘‘[country name] + emerg*’’ (n = 26 670) CINAHL search (excluding PubMed): ‘‘[country name] + emerg*’’ (n = 1072) World Health Organization regional indices search: ‘‘[country name] + emerg*’’ (n = 7176) Google Scholar search: ‘‘allintitle: [country name] + emerg*’’ (n = 6236) Non-indexed journal manual search: (n = 1955) Forward and backward reference search (n = 33) Personal communication (n = 16) Records screened (n = 43 109) Full-text articles assessed for eligibility (n = 1192) Articles on general emergency care (n = 162) Studies included in quantitative analysis (n = 211) Records excluded • Based on relevance (n = 41 909) • Potentially relevant but full-text records untraceable (n = 8) Excluded (n = 1030) • Studies that relate to specific disease categories • Studies that relate only to subgroups of emergency patients • Articles that are general descriptions of emergency care, without data on individual facilities • Articles that only present aggregated data from multiple facilities • Articles that were published before 1990 IQR: 10 994–61 313). The 17 paediatric facilities in Sub-Saharan Africa had relatively low patient volumes with a median annual patient volume of 3129 (IQR: 2009–7479). The median inpatient admission was 20% (IQR: 10–43%; n = 78) and the median number of beds in the emergency department was 14 (IQR: 8–22; n = 60). The median age of patients attending non-paediatric facilities was 35 years (IQR: 6.9–41.0; n = 51) and a median of 55.7% (IQR: 50.0–59.2%; n = 93) were male. The corresponding values for paediatric facilities were 3.2 years (IQR: 2.8–3.4; n = 13) and 58.3% (IQR: 55.4–60.1%; n = 27), respectively. Table 3 summarizes the training of providers staffing the 102 facilities for which provider data were available. Care in 67 (66%) of these facilities was provided either by trainees or by physicians whose level of training was not specified. In only 29 (28%) of facilities were attending or consultantlevel physicians available full-time; in 19 other facilities, physicians were only available in daytime hours. Eighteen facilities were staffed by specialty-trained emergency physicians, but in only four facilities were emergency physicians available at all times – one in the United Republic of Tanzania (unpublished observations, 2014), one in Pakistan34 and two in Nicaragua.35 One facility provided specialized emergency training to non-physician providers staffing the emergency department.36 In another facility, medical students practising alone were primarily responsible for providing emergency care during most of the day.37 Patients had to navigate through a wide range of options to obtain emergency care and financial factors played a major role in determining what kind of care they received (details available from the corresponding author). Discussion While only a small set of metrics on the delivery of emergency care were reported consistently across facilities, we were able to draw some conclusions on the state of emergency care in lowresource settings. First, large numbers of patients presented to health facilities seeking emergency care. While there was a wide range in annual patient volumes – from just 451 in a paediatric emergency department in Nigeria38 to 273 182 in a general emergency department in Turkey39 – they were approximately 10 times higher than the corresponding caseloads observed in primary care settings in sub-Saharan Africa and Asia.9 Second, patients seeking emergency care were generally young and free of chronic conditions. This is in contrast to the growing burden of elderly patients with multiple chronic conditions seen in the emergency departments of high-income countries.40 Therefore, interventions to decrease mortality and morbidity in emergency settings of LMICs could dramatically increase lifeyears saved and productivity. Third, the mortality recorded in emergency departments in LMICs was many times higher than generally reported in high-income countries.40–42 A recent report on emergency departments in the USA documented a mean mortality within the departments of 0.04%.40 Fourth, most providers of emergency care in LMICs had no specialty training in emergency care. This observation was expected given the general shortages in human resources for health in most of these countries.43 Such shortages may be particularly pronounced Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 579 580 Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 Table 2. Key quantitative data for emergency departments, 59 low- and-middle-income countries, 1990–2014 Metric Facility type Unitsa All regions Sub-Saharan Africa No. of beds Annual patient volume (thousands) All All All All General and adult Paediatric n Median (IQR) n Median (IQR) Median (IQR) Median (IQR) 60 14 (8–22) 173 30.0 (10.3–60.0) 36.9 (15.8–64.2) 7.2 (2.3–31.6) 24 9 (8–14) 64 13.6 (3.4–29.8) 16.7 (5.1–35.3) 3.1 (2.0–7.5) Admission, % All n 78 All Median (IQR) 20.0 (10.1–42.8) 26 24.5 (16.5–46.9) General and adult Paediatric Median (IQR) Median (IQR) 18.8 (9.4–40.1) 22.2 (10.7–44.3) 24.5 (15.8–46.5) 33.2 (20.6–65.2) Mortality,%b All All General and adult Paediatric n Median (IQR) Median (IQR Median (IQR) 65 1.8 (0.2–5.1) 0.7 (0.2–3.9) 4.8 (2.3–8.4) 44 3.4 (0.5–6.3) 0.9 (0.2–4.8) 5.1 (3.5–11.1) IQR: interquartile range; NA: not available. a For each metric and region, the number of facilities for which the relevant data were available (n) is indicated. b Within the emergency department. Data sources: Table 1, (available at: http://www.who.int/bulletin/volumes/93/14/07-148338). South Asia, East Asia & Pacific 20 21 (15–23) 35 36.5 (8.3–70.0) 50.0 (29.2–81.2) 5.6 (2.2–7.6) 16 26.0 (15.0–38.7) 24.2 (15.0–36.3) Middle East & North Africa 4 11 (8–25) 24 49.0 (34.0– 68.8) 53.6 (34.0– 79.0) 43.0 (22.1– 44.3) 15 18.2 (10.1– 22.2) 14.9 (7.7–18.9) 32.5 (14.0–43.0) 9 0.3 (0.2–0.8) 0.3 (0.2–0.5) 21.8 (15.7– 28.6) 5 0.7 (0.2–2.1) 0.5 (0.2–1.4) 0.8 (< 0.1–2.7) 7.8 (NA) Latin America & Caribbean 9 17 (12–22) 42 52.4 (26.0– 87.0) 59.7 (31.0– 89.1) 27.5 (13.5– 68.1) 20 11.1 (3.9–20.7) 10.2 (3.9–19.5) 14.3 (6.4–35.4) 7 2.0 (0.1–7.4) 2.0 (0.1–7.4) NA (NA) Europe & Central Asia 3 16 (16–27) 8 33.8 (15.3– 72.1) 36.5 (14.6– 82.1) 31.0 (NA) 1 50.0 (NA) 50.0 (NA) NA (NA) NA NA (NA) NA (NA) NA (NA) Ziad Obermeyer et al. Systematic reviews Emergency care in low- and middle-income countries Ziad Obermeyer et al. Systematic reviews Emergency care in low- and middle-income countries Table 3. Training of providers of emergency care included in systematic analysis, 48 low- and-middle-income countries, 1991–2014 Region,a country No. of facilities Nonphysician or medical student Physician in training or with unspecified level of training Attending physician or consultant Emergency physician Sub-Saharan Africa Botswana Burkina Faso Cameroon Congo Eritrea Ghana Kenya Liberia Madagascar Malawi Namibia Nigeria Rwanda Seychelles Sierra Leone South Africa Sudan Uganda United Republic of Tanzania South Asia, East Asia & Pacific China India Kazakhstan Malaysia Nepal Pakistan Papua New Guinea Viet Nam Latin America & Caribbean Brazil Cuba Ecuador Guyana Jamaica Mexico Nicaragua Paraguay Saint Vincent and the Grenadines Middle East & North Africa Egypt Islamic Republic of Iran Jordan Lebanon Morocco Tunisia Europe & Central Asia Belarus – – – 1 – – – – – – – – – – – – – 1b – – – – – – – – – – – – – – – – – – – – – – – – – 1 1 1 – 1 2 1 1 1 – 1 4 1 1 1 8 2 – 2 2 3 1 2 4 2 1 2 1 – 3 1 – 1 – 1 1 1 1 4 – 1 1 1 – 1b –– 1b – 1b – –– –– –– 1b – 1– 2– –– 2 1b –– –– –– 4 1b – 2c –– –1 2b – 7c – –– – 1b 3d 1b 11 –– –– 3– 2– 1b – –– 1 1b – 1b –2 –1 –– 1b – –– 3d 1b 1 1b 1b – 1b – 1b – (continues. . .) Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 in emergency settings, where the work is demanding and salaries are often poor. Most governments do not include emergency medicine in their medical education priorities. What implications do these results have for LMICs? We made a rough calculation for Nigeria, where we identified relevant studies in 21 facilities and mean annual patient volume of 3000 and 5–7% mortality. If we assume that the approximately 1000 teaching and general hospitals44 in the country have the same mean annual patient volume and mortality, then out of the 1.6 million deaths recorded annually in Nigeria45 an estimated 10–15% occur in emergency departments. This estimate – and the observation that most emergency departments in LMICs are run by providers with no speciality training in emergency care – illustrates the opportunity to improve emergency care in LMICs. It is likely that relatively simple interventions to facilitate triage and improve patient flow, communication and the supervision of junior providers (Box 1) could lead to reductions in the mortality associated with emergency care.46–49 Our data illustrate the unique cost–benefit profile of investments in emergency care. Although disease and injury prevention are key functions of all health systems, acute health problems – e.g. myocardial infarction, sepsis and trauma – continue to occur in all countries. With the same amount of resources, it is likely that more lives could be saved in a paediatric emergency facility with mortality between 12% and 21%50–52 than in paediatric primary-care clinics in similar settings – which generally see just a few critically-ill children per clinic per week (unpublished observations, 2015). There is thus a clear case for investing in emergency care in LMICs, to complement existing efforts to strengthen primary and preventive care. Implications for policy What is needed to strengthen emergency care in LMICs? First, a better understanding of the conditions that drive patients to seek such care is crucial. We documented high patient volumes and mortality but did not identify the diseases or the conditions that drive these metrics. While useful estimates of the burden of acute conditions may be produced in mathematical models,53 581 Systematic reviews Emergency care in low- and middle-income countries Ziad Obermeyer et al. (. . .continued) son, there are about 5000 emergency Region,a country No. of facilities departments in the USA.56 The facilities we identified were largely urban and Non- Physician in Attending Emergency academic – as might be expected given physician training or with physician or physician that our search strategy relied mainly or medical unspecified level consultant on published reports. Broader report- student of training ing biases may also have affected our Bosnia and Herzegovina –2 – 1b results. For example, facilities with fewer Hungary –– 1 – resources may be relatively unlikely to Romania –– 1 1b collect and publish data and facilities Serbia Turkey Ukraine – – – – 1 1 1 2b 3b – 1b – with exceptionally high levels of mortality may be relatively unlikely to publish those levels. Thus, our results are likely to present an optimistic view of the state a Regions according to the World Bank.30 b Provider only available part-time in the facility or one of the facilities. c Provider only available part-time in two of the facilities. d Provider only available part-time in three of the facilities. Data sources listed in Table 1, (available at: http://www.who.int/bulletin/volumes/93/14/07-148338). of emergency care in LMICs. Regional comparisons must be viewed with caution, given the geographical variation in facility charac- teristics and reporting practices. For ex- the setting of specific clinical and policy purpose-designed to capture data for ample, emergency departments in which priorities remains difficult because of the clinicians, administrators and research- patients have exceptionally long lengths scarcity of relevant data. ers in LMICs. A novel data collection of stay will probably also have exception- Second, once we have a better platform has been implemented for ally high mortality – since patients who understanding of the burden of acute trauma care in a large teaching hospital stay longer in the department are more disease, interventions known to be ef- in the United Republic of Tanzania, with likely to die in the department. Although fective in high-income settings – e.g. promising early results. The systematic a lack of relevant data prevented us trauma resuscitation training – must integration of routine data collection from investigating this relationship, the be adapted to LMICs and critically into care delivery settings should help median length of stay in our sample – assessed. Some effective interventions ensure that interventions are – and albeit in the small number of facilities to decrease mortality in emergencies remain – effective. that reported lengths of stay – was only (Box 1) may only require the improved use of existing system components, Limitations 7.7 hours. It therefore seems unlikely that prolonged stays alone could have with the minimal input of new material The most important limitation of our accounted for the high levels of mortal- resources. However, assessing the effec- study is the general paucity of data on ity that we observed. tiveness of such interventions by rigor- emergency care. After screening over Other limitations were our search ous experimental or quasi-experimental 40 000 published reports, we identified strategy, which relied on the presence methods requires additional funding. relevant data from only 192 facilities of at least one word that began with Although before-and-after comparisons spread across 59 LMICs. For compari- “emerg” in the title, keywords or abstract may be easier, they are also vulnerable to a range of biases.54 Third, international organizations must accelerate efforts to develop consensus on the essential compo- Box 1. Interventions to reduce mortality from medical emergencies in four low- or middle-income countries nents of systems for emergency care. Rural districts in Cambodia and northern Iraq Policy-makers who wish to assess their Local paramedics and lay first responders were trained to provide field care for trauma. After emergency systems and set priorities the intervention, the trauma mortality decreased from 40% to 15%.46 for development need technical guid- Queen Elizabeth Hospital, Malawi ance. WHO’s framework on systems of The paediatric clinic was physically restructured to streamline operations, clinical staff were trauma care is one useful model for this broad agenda.55 Finally, improvements to emergen- trained in emergency care and triage and cooperation between the inpatient and outpatient services was improved. After the intervention, mortality within 24 hours of presentation decreased from 36% to 13%.47 cy care in LMICs will require advances Ola During Children’s Hospital, Sierra Leone in data collection. The development of a minimum set of indicators for emergency care in LMICs would facilitate research and quality improvement.21 Several actors are improving platforms for data collection in LMICs. For example, the African Federation for Emergency Medicine is building consensus around a medical chart that has been A triage unit was established in the outpatient department and the emergency and intensive care units were combined. Clinical staff were trained in emergency care and triage, with experienced nursing and medical officers required to be present at all times. Equipment and record keeping were also enhanced. After the intervention, inpatient mortality decreased from 12% to 6%.48 Kamuzu Central Hospital, Malawi The paediatric clinic allocated senior medical staff to supervise emergency care and implemented formal triage procedures, with an emphasis on early patient treatment and stabilization before transfer to the inpatient ward. Inpatient mortality within two days of admission decreased, from 5% to 4%.49 582 Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 Ziad Obermeyer et al. Systematic reviews Emergency care in low- and middle-income countries of an article. While this made a difficult search problem tractable, it may also have excluded some relevant studies. Also, lack of data standardization across facilities and countries probably biased our results. For example, standardized measures of mortality – e.g. the percentage of patients that died with 24 hours of their presentation – were seldom reported, probably because of the difficulties of following-up patients after they leave the emergency department. The maximum age for a so-called paediatric patient also varied widely across studies, from five to 19 years.57,58 Conclusion Emergency facilities in LMICs serve a large, young patient population with high levels of critical illnesses and mortality. This suggests that emergency care should be a global health priority. The cost–benefit ratio for improvements in emergency care is likely to be highly favourable, given the high volume of patients for whom high-quality care could be the difference between life and death. There are likely to be substantial opportunities to improve care and im- pact outcomes, in ways that could be rigorously evaluated with manageable sample sizes. ■ Acknowledgements Ziad Obermeyer and Stephanie Kayden are also affiliated with Brigham and Women’s Hospital, Boston. Other members of the Acute Care Development Consortium: Mark Bisanzo (Global Emergency Care Collaborative, Uganda), Amit Chandra (Princess Marina Hospital, Gaborone, Botswana), Cindy Y. Chang (Harvard Affiliated Emergency Medicine Residency, Boston, USA), Kirsten Cohen (New Somerset Hospital, Cape Town, South Africa), Joshua J Gagne (Brigham and Women’s Hospital Boston, USA), Eveline Hitti (American University of Beirut Medical Center, Beirut, Lebanon), Bonaventure Hollong (University of Cape Town, Cape Town, South Africa), Steven Holt (ER Consulting Inc., Johannesburg, South Africa), Vijay Kannan (University of Texas Southwestern Medical Center, Dallas, USA), Roshen Maharaj (King Dinuzulu Hospital Complex, Durban, South Africa), Roseda Marshall (John F. Kennedy Medical Center, Monrovia, Liberia), Hani Mowafi (Yale University School of Medicine, New Haven, USA), Michelle Niescierenko (Boston Children’s Hospital, Boston, USA), Maxwell Osei-Ampofo (Komfo Anokye Teaching Hospital, Kumasi, Ghana), Junaid Razzak (Aga Khan University Hospital, Karachi, Pakistan), Rasha Sawaya (Childrens National Medical Center, Washington DC, USA), Hendry R Sawe (Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania), Stefan Smuts (Mediclinic Southern Africa, South Africa), Sukhjit Takhar (Brigham and Women’s Hospital, Boston, USA), Eva Tovar-Hirashima (Harvard Affiliated Emergency Medicine Residency, Boston, USA), Benjamin Wachira (Aga Khan University Hospital, Nairobi, Kenya) Funding: This research was supported financially by a United States National Institutes of Health grant (DP5-OD012161) awarded to Brigham and Women’s Hospital, Boston. Competing interests: None declared. ‫ملخص‬ :‫بل ًدا من البلدان منخفضة الدخل والبلدان متوسطة الدخل‬ 59 ‫الرعاية الصحية المقدمة في حالات الطوارئ في‬ ‫منهجية‬ ‫مراجعة‬ ‫ حيث كان معظمهم من الشباب‬،)60,000 – 10,296 :‫الغرض إجراء مراجعة منهجية للرعاية المقدمة في حالات الطوارئ الربيعي‬ ‫) والذكور‬41.0 – 9.6 :‫ عا ًما؛ المدى الربيعي‬35 :‫ (متوسط العمر‬.)LMIC( ‫في البلدان منخفضة الدخل والبلدان متوسطة الدخل‬ ‫ وضم فريق‬.)59.2%–50.0 :‫؛ المدى الربيعي‬55.7% :‫ والدليل (المتوسط‬،PubMed ‫الطريقة لقد بحثنا في قواعد البيانات في موقع‬ ‫التراكمي للنشريات في مجال التمريض والمهن الصحية المساعدة العمل بمعظم المؤسسات إما أطباء في مرحلة التدريب أو أطباء‬ ‫ وتوفر لدى عدد قليل ج ًدا‬.‫) عن تقارير ذوي مستوى غير محدد من التدريب‬WHO( ‫ ومنظمة الصحة العالمية‬،)CINAHL( ‫ من هذه الجهات المقدمة للخدمة الصحية تدريب تخصصي في تقديم‬.‫تبين الرعاية المقدمة في حالات الطوارئ داخل المؤسسات الصحية‬ .‫وقد استطلعنا بعض المقالات لتضمينها في المراجعة حسب العناوين الرعاية الصحية في حالات الطوارئ‬ ‫ واستخلصنا الاستنتاج تشير البيانات المتوفرة عن تقديم الرعاية الصحية في‬.‫والملخصات الواردة باللغة الإنجليزية أو الفرنسية‬ ‫بيانات بشأن النتائج المتعلقة بالمرضى والخصائص الديموغرافية حالات الطوارئ في البلدان منخفضة الدخل والبلدان متوسطة‬ ‫ واقتصرت الدخل إلى ارتفاع عدد المرضى لدى الأطباء المتدربين وارتفاع عدد‬.‫وخصائص المؤسسات والجهات المقدمة للخدمات‬ ،‫ خاص ًة في الدول الواقعة جنوب الصحراء الأفريقية‬،‫الوفيات‬ .1990 ‫التحليلات على التقارير المنشورة منذ عام‬ ‫مؤسسة في حيث حُيتمل وقوع نسبة كبيرة من جميع حالات الوفاة في أقسام‬ 192 ‫تقري ًرا يتعلق بـ‬ 195 ‫النتائج توصلنا إلى تحديد‬ ‫ وإن اجتماع عنصر ارتفاع العدد وعنصر الحاجة الملحة‬.‫ وكان معظم المؤسسات يمثل مستشفيات تابعة لجهات الطوارئ‬.‫دولة‬ 59 ‫ وبلغ متوسط نسبة الوفيات داخل للعلاج يجعل تقديم الرعاية الصحية في حالات الطوارئ نقطة‬.‫أكاديمية في مناطق حضرية‬ ‫ وكانت هامة تستحق التركيز عليها في التدخلات التي تهدف إلى تقليل‬.)5.1%–0.2 :‫ (المدى الربيعي‬1.8% ‫أقسام الطوارئ‬ .‫ نسبة الوفيات في مثل هذه المناطق‬:‫نسبة الوفيات مرتفعة نسب ًيا في مؤسسات علاج الأطفال (المتوسط‬ ‫) وفي الدول الواقعة في‬8.4% – 2.3 :‫الم��دى الربيعي‬ ‫؛‬4.8% :‫؛ المدى الربيعي‬3.4% :‫جنوب الصحراء الأفريقية (المتوسط‬ ‫ في السنة (المدى‬30,000 ‫ وبلغ متوسط عدد المرضى‬.)6.3%–0.5 Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 583 Systematic reviews Emergency care in low- and middle-income countries Ziad Obermeyer et al. 摘要 59 个中低收入国家中的急救护理 ：系统评审 目的 旨在对中低收入国家 (LMIC)  中的急救护理进行 系统评审。 方 法 我 们 从 PubMed、CINAHL  和 世 界 卫 生 组 织 (WHO)  数据库中搜索了描述机构中急救护理的报 告，并且从临床医生和研究人员网络中获取了未经 发布的数据。 我们根据其英语或法语标题和摘要筛 选了所包含的文章。 我们针对患者疗效和人口统计 以及机构和提供方的特性提取了数据。 分析仅限于 自 1990 年以来发布的报告。 结 果 我 们 确 定 了 涉 及 59  个 国 家 中 192  家 机 构 的 195  份报告。 其中大部分为城市地区的学院附属 医院。 急诊部内的平均死亡率为 1.8%（四分位差， IQR：0.2 至 5.1%）。死亡率在儿科也相对较高（平均值： 4.8% ；IQR ：2.3  至 8.4%），而且在撒哈拉以南的非洲 死亡率也比较高（平均值 ：3.4% ；IQR ：0.5 至 6.3%）。 患者平均为每年 30 000 例（IQR ：10 296 至 60 000），其 中大部分为年轻人（平均年龄：35 岁；IQR：6.9 至 41.0） 和男性（平均值 ：55.7% ；IQR ：50.0  至 59.2%）。大多 数机构中的工作人员为实习医生或未指定培训水平的 医生。 这些提供方中仅有非常少的一部分接受过急救 护理方面的专业培训。 结论 中低收入国家 (LMIC)  中现有的急救护理数据表 明患者数量和死亡率很高，特别是在撒哈拉以南的非 洲，所有死亡中有相当大的一部分比例是发生在急诊 部。 治疗量大并且具有紧急性这两个特点的结合让急 救护理在我们采取以降低这些环境中的死亡率为目的 的干预措施时成为关注的重点领域。 Résumé Les soins d’urgence dans 59 pays à revenu faible ou intermédiaire: examen systématique Objectif Réaliser un examen systématique des soins d’urgence dans (moyenne: 4,8%; IQR: 2,3–8,4%) et en Afrique subsaharienne (moyenne: les pays à revenu faible ou intermédiaire (PRFI). 3,4%; IQR: 0,5–6,3%). Le nombre moyen de patients était de 30 000 par MéthodesNousavonsrecherchédanslesbasesdedonnéesdePubMed, an (IQR: 10 296–60 000), la plupart d’entre eux étant des jeunes (âge CINAHL et de l’Organisation mondiale de la Santé des rapports décrivant médian: 35 ans; IQR: 6,9–41,0) et de sexe masculin (moyenne: 55,7%; IQR: les soins d’urgence dispensés dans les établissements médicaux et 50,0–59,2%). La majorité des établissements employaient des médecins obtenu des données non publiées auprès d’un réseau de cliniciens et en formation ou dont le niveau de formation n’était pas précisé. Rares de chercheurs. Nous avons sélectionné plusieurs articles à inclure d’après étaient les prestataires à avoir reçu une formation spécialisée en soins leur titre et leur résumé en anglais ou en français. Nous avons extrait d’urgence. des données liées à l’état de santé des patients, à la démographie et aux Conclusion Les données existantes concernant les soins d’urgence caractéristiques des établissements et des prestataires. Les analyses se dispensés dans les PRFI indiquent un nombre de patients et une sont limitées à des rapports publiés à partir de 1990. mortalité élevés, en particulier en Afrique subsaharienne où une fraction Résultats Nous avons identifié 195 rapports relatifs à 192 établissements importante de l’ensemble des décès est susceptible de survenir dans implantés dans 59 pays. Il s’agissait pour la plupart d’hôpitaux les services d’urgence. Compte tenu du nombre élevé et de l’urgence universitaires situés dans des zones urbaines. La mortalité moyenne au des interventions, les soins d’urgence constituent un domaine d’intérêt sein des services d’urgence était de 1,8% (intervalle interquartile, IQR: important pour les actions visant à réduire la mortalité dans ces lieux. 0,2–5,1%). Elle était relativement élevée dans les centres pédiatriques Резюме Неотложная помощь в 59 странах с низким и средним уровнем дохода: систематический обзор Цель Систематизированный анализ неотложной помощи в Африке к югу от Сахары (медиана: 3,4%; МКР: 0,5–6,3%). Среднее странах с низким и средним уровнем доходов населения. количество пациентов составляло 30 000 человек в год (МКР: Методы В базах данных PubMed, CINAHL и Всемирной 10 296–60 000), большинство из которых были молодого возраста организации здравоохранения (ВОЗ) был проведен поиск отчетов (средний возраст: 35 лет; МКР: 6,9–41,0) и мужского пола (медиана: по оказанию неотложной помощи в медицинских учреждениях. 55,7%; МКР: 50,0–59,2%). Большинство медицинских учреждений Кроме того, были получены неопубликованные данные от сети были укомплектованы врачами-стажерами или врачами, уровень практикующих врачей и исследователей. Статьи отбирались подготовки которых не указывался. Лишь небольшое число по названию и аннотации на английском или французском из рассмотренных поставщиков медицинских услуг обладали языке. Отбирались данные по результатам лечения пациентов и специальной подготовкой в области неотложной помощи. демографические данные, а также информация о характеристиках Вывод Доступные данные по оказанию неотложной помощи в медицинского учреждения и поставщиков медицинских услуг. странах с низким и средним уровнем доходов свидетельствуют Анализировались только отчеты, опубликованные с 1990 года. о большой численности поступающих больных и высоком Результаты Было отобрано 195 отчетов по 192 медицинским уровне смертности, особенно в Африке к югу от Сахары, где учреждениям в 59 странах. Большинство из этих учреждений существенная доля всех смертельных случаев приходится на являются академическими больницами, расположенными в отделения неотложной помощи. Высокий объем инцидентов и городскихрайонах.Средняясмертностьвотделенияхнеотложной срочность необходимого лечения свидетельствуют о том, что помощи составляла 1,8% (межквартильный размах, МКР: 0,2–5,1%). неотложная помощь является одной из важнейших областей, на Смертность была относительно высокой в педиатрических которую следует направить мероприятия по снижению уровня медицинских учреждениях (медиана: 4,8%; МКР: 2,3–8,4%) и в смертности в указанных условиях. 584 Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 Ziad Obermeyer et al. Systematic reviews Emergency care in low- and middle-income countries Resumen La atención de emergencia en 59 países de ingresos medios y bajos: revisión sistemática Objetivo Realizar una revisión sistemática de la atención de emergencia relativamente alta en los centros pediátricos (mediana: 4,8%; RIC: en países de ingresos medios y bajos (PIMB). 2,3–8,4%) y en el África subsahariana (mediana: 3,4%; RIC: 0,5–6,3%). Métodos Se realizaron búsquedas en las bases de datos de PubMed, La mediana de pacientes era de 30.000 al año (RIC: 10.296–60.000), la CINAHL y la Organización Mundial de la Salud (OMS) para encontrar mayoría de los cuales eran jóvenes (mediana de edad: 35 años; RIC: informes que describieran la atención de emergencia en centros 6,9–41,0) y hombres (mediana: 55,7%; RIC: 50,0–59,2%). El personal de sanitarios y se obtuvieron datos sin publicar de una red de clínicos e la mayoría de los centros eran médicos en formación o médicos cuyo investigadores. Se seleccionaron artículos para ser incluidos en base a nivel de formación era indeterminado. Muy pocos de estos proveedores los títulos y resúmenes en inglés o francés. Se recogieron datos de los tenían una formación especializada en atención de emergencia. resultados y demografías de los pacientes, así como características de Conclusión Los datos disponibles en atención de emergencia en las instalaciones y los proveedores. Los análisis se redujeron a informes PIMB indican una gran carga de pacientes y mortalidad, en especial en publicados a partir de 1990. el África subsahariana, donde una proporción sustancial de todas las Resultados Se identificaron 195 informes referentes a 192 instalaciones muertes pueden ocurrir en los servicios de urgencias. La combinación en 59 países. La mayoría eran hospitales académicamente afiliados entre una gran carga y la urgencia del tratamiento hacen de la atención en zonas urbanas. 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Identified studies on the delivery of emergency care in low- and middle-income countries Author Year Title Journal Country or area A-Rahman NHA 2014 The state of emergency care in the Republic of the Sudan Afr J Emerg Med Sudan Abbadi S et al 1997 Emergency medicine in Jordan Ann Emerg Med Jordan Abd Elaal SAM et al 2006 The waiting time at emergency departments at Khartoum State-2005 Sudan J Public Health Sudan Abdallat AM et al 2007 Frequent attenders to the emergency room at Prince Rashed Bin J R Med Serv Al-Hassan Hospital Jordan Abdallat AM et al 2000 Who uses the emergency room services? Eastern Mediterr Health J Jordan Abhulimhen-Iyoha BI et al 2012 Morbidity and mortality of childhood illnesses at the emergency Nigeria J Pediatr paediatric unit of the University of Benin Teaching Hospital, Benin City Nigeria Adeboye MAN et al 2010 Mortality pattern within twenty-four hours of emergency paediatric admission in a resource-poor nation health facility West Afr J Med Nigeria Adesunkanmi ARK et al 2002 A five year analysis of death in accident and emergency room of West Afr J Med a semi-urban hospital Nigeria Afuwape OO et al 2009 An audit of deaths in the emergency department in the University College Hospital Ibadan Nigeria J Clin Pract Nigeria Aggarwal P et al 1995 Utility of an observation unit in the emergency department of a European J Emerg Med India tertiary care hospital in India Akpa MR et al 2013 Profile and outcome of medical emergencies in a tertiary health Nigeria Health J institution in Port Harcourt, Nigeria Nigeria Al-Hakimi ASA et al 2004 Load and pattern of patients visiting general emergency AlThawra Hospital, San a’a Yemen Health Medical Yemen Res J Alagappan K et al 1998 Early development of emergency medicine in Chennai (Madras), Ann Emerg Med India India Asumanu E et al 2009 Improving emergency attendance and mortality – the case for unit separation West Afr J Med Ghana Atanda HL et al 1994 Place des urgences medicales pediatriques dans un service medical a Pointe-Noire Med Afr Noire Congo Avanzi MP et al 2005 Diagnósticos mais freqüentes em serviço de emergência para adulto de um hospital universitário Rev Ciênc Méd Brazil Azhar AA et al 2000 Patient attendance at a major accident and emergency department: Are public emergency services being abused? Med J Malaysia Malaysia Bains HS et al 2012 A simple clinical score “TOPRS” to predict outcome in pediatric emergency department in a teaching hospital in India Iran J Pediatr India Bamgboye EA et al 1990 Mortality pattern at a children’s emergency ward, University College Hospital, Ibadan, Nigeria Afr J Med Med Sci Nigeria Basnet B et al 2012 Initial resuscitation for Australasian Triage Scale 2 patients in a Nepalese emergency department Emerg Med Australas Nepal Batistela S et al 2008 Os motivos de procura pelo Pronto Socorro Pediátrico de um Hospital Universitário referidos pelos pais ou responsáveis Semina: Ciênc Biológicas Brazil Saúde Bazaraa HM et al 2012 Profile of patients visiting the pediatric emergency service in an Pediatr Emerg Care Egyptian university hospital Egypt Ben Gobrane HLB et al 2012 Motifs du recours aux services d’urgence des principaux hôpitaux East Mediterr Health J du Grand Tunis Tunisia Berraho M et al 2012 Les consultations non approprieés aux services des urgences: étude dans un hôpital provincial au Maroc Prat Organ Soins Morocco Boff JM et al 2002 Perfil do Usuário do Setor de Emergência do Hospital Universitário da UFSC Rev Contexto Saude Brazil Boros MJ 2003 Emergency medical services in St. Vincent and the Grenadines Prehosp Emerg Care St. Vincent and the Grenadines Bresnahan KA et al 1995 Emergency medical care in Turkey: current status and future directions Ann Emerg Med Turkey Brito MVH et al 1998 Pronto-atendimento de adultos em serviço de saúde universitário: um estudo de avaliação Rev Adm Publica Brazil Brito MVH et al 2012 Perfil da demanda do serviço de urgência e emergência do hospital pronto socorro municipal- Mario Pinotti Rev Paraense Med Brazil Brown MD 1999 Emergency medicine in Eritrea: rebuilding after a 30-year war Am J Emerg Med Eritrea (continues. . .) Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 586A Systematic reviews Emergency care in low- and middle-income countries Ziad Obermeyer et al.  (. . .continued) Author Bruijns S et al Burch V et al Buys H et al Cander B et al Carret MLV et al Carret MLV et al Cevik AA et al Chattoraj A et al Chukuezi AB et al Clark M et al Clarke ME Clem KJ et al Coelho MF et al Coelho MF et al Cox M et al Curry C et al da Silva GS et al Dalwai M et al Damghi N et al Dan V et al de Souza LM et al De Vos P et al Derlet RW et al Dubuc IF et al Duru C et al Ekere AU et al Enobong EI et al Erickson TB et al Eroglu SE et al Year Title Journal Country or area 2008 A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa Emerg Med J South Africa 2008 Modified early warning score predicts the need for hospital admission and inhospital mortality Emerg Med J South Africa 2013 An adapted triage tool (ETAT) at Red Cross War Memorial Children’s Hospital Medical Emergency Unit, Cape Town: an evaluation S Afr Med J South Africa 2006 Emergency operation indications in emergency medicine clinic Adv Ther (model of emergency medicine in Turkey) Turkey 2007 Demand for emergency health service: factors associated with inappropriate use BMC Health Serv Res Brazil 2011 Características da demanda do serviço de saúde de emergência Cien Saude Colet no Sul do Brasil Brazil 2001 Update on the development of emergency medicine as a specialty in Turkey European J Emerg Med Turkey 2006 A study of sickness & admission pattern of patients attending an J AcadHosp Adm emergency department in a tertiary care hospital India 2010 Pattern of deaths in the adult accident and emergency department of a sub-urban teaching hospital in Nigeria Asian J Med Sci Nigeria 2012 Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone PLoS one Sierra Leone 1998 Emergency medicine in the new South Africa Ann Emerg Med South Africa 1998 United States physician assistance in development of emergency Ann Emerg Medi medicine in Hangzhou, China China 2010 Analysis of the organizational aspects of a clinical emergency department: a study in a general hospital in Ribeirao Preto, SP, Brazil Rev Lat Am Enfermagem Brazil 2013 Urgências clínicas: perfil de atendimentos hospitalares Rev Lat Am Enfermagem Brazil 2007 Emergency medicine in a developing country: experience from Emerg Med Australas Kilimanjaro Christian Medial Centre, Tanzania, East Africa The United Republic of Tanzania 2004 The first year of a formal emergency medicine training programme in Papua New Guinea Emerg Med Australas Papua New Guinea 2007 Caracterização do perfil da demanda da emergência de clínica médica do hospital universitário da Universidade Federal de Santa Catarina Arq Catarinenses Med Brazil 2013 Implementation of a triage score system in an emergency room Public Health Action in Timergara, Pakistan Pakistan 2013 Patient satisfaction in a Moroccan emergency department Intl Arch Med Morocco 1991 Prise en charge des urgences du nourrisson et de l’enfant: aspects Med Afr Noire actuels et perspectives d’avenir Benin 2011 Risk classification in an emergency room: agreement level between a Brazilian institutional and the Manchester Protocol Rev Lat Am Enfermagem Brazil 2008 Uses of first line emergency services in Cuba Health Policy Cuba 2000 Emergency medicine in Belarus J Emerg Med Belarus 2006 Adolescentes atendidos num serviço púlico de urgência e emergência: perfil de morbidade e mortalidade Rev Eletrônica Enfermagem Brazil 2013 Pattern and outcome of admissions as seen in the paediatric Nigeria J Pediatr emergency ward of the Niger Delta University Teaching Hospital Bayelsa State, Nigeria Nigeria 2005 Mortality patterns in the accident and emergency department of Nigeria J Clinic Pract an urban hospital in Nigeria Nigeria 2009 Pattern of paediatric emergencies and outcome as seen in a tertiary hosptial: a five-year review Sahel Med J Nigeria 1996 Emergency medicine education intervention in Rwanda Ann Emerg Med Rwanda 2012 Evaluation of non-urgent visits to a busy urban emergency department Saudi Med J Turkey 586B (continues. . .) 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Systematic reviews Emergency care in low- and middle-income countries  (. . .continued) Author Year Title Journal Country or area Tannebaum RD et al Taye BW et al Tiemeier K et al Tinaude O et al Tintinalli J et al Topacoglu H et al Traoré A et al Trejo JA et al Tsiperau J et al Ugare GU et al Veras JEG et al Veras JEG et al Wang L et al Webb HR et al Williams EW et al Wright SW et al Yaffee AQ et al Yildirim C et al Zhou JC et al 2001 Emergency Medicine in Southern Brazil Ann Emerg Med Brazil 2014 Quality of emergency medical care in Gondar University Referral BMC Emerg Med Hospital, north-west Ethiopia: a survey of patient’s perspectives: a survey of patients’ perspectives Ethiopia 2013 The effect of geography and demography on outcomes of emergency department patients in rural Uganda Ann Emerg Med Uganda 2010 Health-care-seeking behaviour for childhood illnesses in a resource-poor setting J Paediatr Child Health Nigeria 1998 Emergency care in Namibia Ann Emerg Med Namibia 2004 Analysis of factors affecting satisfaction in the emergency department: a survey of 1 019 patients Adv Ther Turkey 2002 Les urgences médicales au Centre hospitalier national Yalgado Ouédraogo de Ouagadougou : profil et prise en charge des patients Cah Etud Rech Francophones / Santé Burkina Faso 1999 El servicio de urgencias en un hospital de tercer nivel. 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Additional data were obtained through personal communications from: Botswana (1), Cameroon (1), Ghana (1), Lebanon (1), Liberia (1), Madagascar (1) and South Africa (10). Bull World Health Organ 2015;93:577–586G| doi: http://dx.doi.org/10.2471/BLT.14.148338 586G