Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study
Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study
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DOI：
10.1016/j.afjem.2018.10.002
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发表时间：
2019-03-01
影响因子：
1.3
通讯作者：
Levine, Adam C.
中科院分区：
文献类型：
--
作者：
Aluisio, Adam R.;Barry, Meagan A.;Levine, Adam C.
简介：虽然急诊医学（EM）培训计划已开始在低收入和中等收入国家（LMICs）推出，但在这种情况下，其对以患者为中心的结果的影响的数据很少。本研究评估了EM培训和相关系统实施对在大学教学医院基加利（UTH-K）治疗的患者死亡率的影响：在UTH-K EM研究生文凭课程于2013年10月启动，随后在2015年8月进行住院培训计划。在2013年10月之前，护理完全由全科医生提供;此后，护理由全科医生和少数民族受训人员轮流提供。在2012年11月至2013年10月（培训前）和2015年8月至2016年7月（培训后）期间寻求急诊中心（EC）护理的患者有资格入选。使用结构化协议从记录的随机样本中提取数据。主要结局为EC和总体住院死亡率。死亡率，患病率和风险差异（RD）进行了比较培训前和培训后。使用回归模型量化效应的大小，以获得调整后的比值比（aOR）和95%置信区间（CI）。中位年龄为32岁，男性居多（60.7%）。训练前EC死亡率为6.3%（95% CI 5.3-7.5%），而训练后EC死亡率为1.2%（95% CI 0.7-1.8%），在校正分析中显著降低（aOR = 0.07，95% CI 0.03-0.17; p < 0.001）。培训前的总体住院死亡率为12.2%（95% CI 10.9-13.8%）。培训后的总体住院死亡率为8.2%（95% CI 6.9-9.6%），导致死亡可能性降低43%（aOR = 0.57，95% CI 0.36-0.94; p = 0.016）。讨论在研究的人群中，EM培训和系统实施与死亡率显著降低相关，表明潜在的患者-在资源有限的环境中，以EM开发的利益为中心。
Introduction: Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K).Methods: At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).Results: From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016).Discussion In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resourcelimited settings.