Pre-Hospital Care in Nigeria

BACKGROUND

A report on the global competitiveness of emerging economies reveals that only nations, whose people can acclimatize their thought to drive home constant, continuous innovations in the era of the 21st-century globalization, will emerge as a sustainable economy.

With the emergence of AI (Artificial Intelligence) taking over many jobs, it is argued that jobs like Medicine and Paramedicine that have to do with empathy, passion, and compassion might never be replaced by robots.

While this assertion is debatable, it can also be argued that only individuals (Health Care Provider) who can think critically, creatively, innovatively and independently to be able to meet and adapt to the complexities of humans, innovate and horn their professional skills to meet the technological advancement in the health sector will have a role to play in the future.

As many career- seekers know that healthcare is one of the most rapidly expanding fields and a projected emergency medical service practice in Nigeria by the Federal Government would make Paramedicine a very attractive education option in the nearest future as medicine is right now.

But the number of jobs isn't the only thing growing in the industry. Many people also envision a new, expanded scope of practice for today's paramedics and healthcare practitioners.

With an increase in the global population from 6.5 billion to 7.3 billion in the last decade, as well as Nigeria is ranked second highest in the rate of road traffic accidents and other emergencies among 193 countries of the world.

It is unarguable that the field of emergency medical services is highly needed in Nigeria and this has sprinted our interest up by establishing Medevac Nigeria Limited to venture into a sustainable and affordable private emergency medical services business.

Every citizen deserves good and quality pre-hospital or emergency care services; from trained, competent, and certified healthcare professionals knowns as Paramedics and dedicated group of companies for emergency medical services provision.

Statistics have shown that; More than 65% of death occurs in the prehospital environment or at the point of admission in the emergency room.

The chances of a patient to recover from an injury or illness increases by 85% if he or she is attended to by a competent and designated healthcare provider in a prehospital environment, with adequate en route care and appropriate disposition to the right hospital or receiving facility.

Meanwhile, for every minute that a casualty or patient is managed by a false provider, the chances of survival are reduced by 19%. Poor patient assessment and mismanagement, inaccessibility to intensive prehospital care, poor patient packaging, en route care, inappropriate disposition, death among others are associated with a lack of true healthcare providers in prehospital settings across the nation, Nigeria.

The healthcare delivery system in Nigeria will remain average or below until a critical fixation is done for Pre-hospital emergency medical services thereby getting the right healthcare professionals to manned the ambulances for effective and improving healthcare delivery and outcomes.

The good results desired will always be unachievable for some state governments running ambulance services or emergency medical services in Nigeria due to lack of incorporating the right professionals into their system for better delivery, performance, and outcome as well as the establishment of an agency to carry out the task successfully.

All of these experiences and facts are some of the values we have incorporated in our Emergency Medical Services at Medevac Nigeria Limited

INTRODUCTION

The global prevalence of road traffic accidents (RTAs) and road traffic injuries (RTIs) is steadily increasing.

According to the World Health Organization, Road Traffic Accidents killed 1.35 million people in 2018 and injured an additional 50 million.

Road Traffic Injuries are now the leading cause of death among children and young adults aged 5–29 years, overtaking HIV/AIDS, diarrheal diseases, and tuberculosis.

This burden is disproportionately higher in low-middle-income countries (LMICs), with 93% of road traffic fatalities occurring in these settings.

Globally, road traffic fatality rates are the highest in the African continent at 26.6 deaths per 100,000.

Nigeria has an annual mortality rate of 20.6 deaths per 100,000 people due to RTAs, in comparison to the USA at 10.8 deaths per 100,000 people and the UK at 2.9 deaths per 100,000 people.

Lagos is the most densely populated state in Nigeria (6710 population per km2), Lagos is divided into 20 local government areas (LGAs) and has an intricate system of road networks managed by various levels of government.

Trunk A roads are maintained by the federal government, Trunk B by the state government, and local roads by the local government with aid from the state government.

Additionally, there are several majors within and interstate expressways throughout Lagos.

Coordinating infrastructure management within these levels of government is difficult and often leads to poor road conditions.

One major concern is the presence of numerous potholes across all types of roads, sometimes large enough to cover more than half the width of the road.

In fact, in 2012, 81% of the roads examined in Lagos had more than 100 potholes, resulting in unsafe road conditions.

The Lagos State Public Works Corporation (PWC) is the government entity "responsible for routine repair and rehabilitation of road across the state, such that they remain motorable all year round".

It coordinates road reconstruction across the state and works with local governments to identify specific issues.

One major issue that it encounters is the weather in Lagos, specifically the rainy season.

The Lagos climate is generally high in humidity with high temperatures, except for a rainy season from June to October.

Not only does this primarily affect the repairs of potholes in the roads, but it also creates drainage issues that further delay these repairs, affecting motor vehicle and pedestrian travel, RTA rates, RTA response times, and prehospital care delivery.

Emergency medical services (EMS) systems are an essential part of the prehospital management of Road Traffic Injuries.

Increased EMS response time has been proven to be associated with higher mortality rates in rural communities and out the sketch of Lagos.

The median urban response time in Africa is 15 min (6–120 min), which is more than double the median urban response time in the United States of America. Currently, in Africa, there are 25 EMS systems in 16 countries, representing merely 30% of the continent.

West Africa is especially underrepresented with Emergency Medical Services systems only present in Ghana and Nigeria.

Oftentimes, the lack of a national emergency management system or prehospital trauma care system results in Emergency Medical Service systems established by state governments or private corporations/establishments like Medevac Nigeria Limited.

This, in turn, leads to a lack of standardized prehospital care delivery within the country. The majority of these systems only provide ambulance transport services as opposed to both transport and paramedic services.

For example, an Emergency Medical Service system in Imo State is staffed entirely by volunteers who are not trained to provide prehospital care.

Contrastingly, in Lagos State, the state government has invested in the Lagos State Ambulance Service (LASAMBUS), which is better equipped to attend to emergencies.

LASAMBUS was established in Lagos in March 2001 as the first Emergency Medical Service system in Nigeria. There are three main EMS systems in Lagos: Lagos State Ambulance Services LASAMBUS, Lagos State Emergency Management Agency (LASEMA), and Lasema Response Unit (LRU).

LASAMBUS uses standard ambulances and there are currently 25 ambulance stations in the state.

When someone calls for an ambulance in the event of Road Traffic Accidents or other accidents, the call is received by a call center in Lagos, which dispatches the ambulance closest to the crash site.

Concurrently, LASAMBUS completes an intervention form detailing the response from when the call was received to when it was concluded.

LASAMBUS then transports the RTA victims to a nearby hospital. Lagos has two main trauma care centers, The Lagos State Accident and Emergency Centre, and the Burns and Trauma Unit at Gbagada General Hospital.

LASAMBUS receives 11,126 calls annually, ranging from trauma cases and general medical cases to hospital transfers.

In 2012, an assessment of LASAMBUS found that RTAs accounted for the largest proportion of calls received.

Additionally, traffic congestion and community disturbance were listed as causes for the delay that LASAMBUS encountered.

The objectives of this study were to:

1. Determine the burden of Road Traffic Accidents in Lagos State.

2. Assess the RTA call outcomes.

3. Analyze LASAMBUS's response time and causes for delay.

4. Introduce a private Emergency Medical Services to support LASAMBUS.

METHODOLOGY

This is a retrospective, cross-sectional study. We received completed LASAMBUS intervention forms that were classified as RTA calls from December 2017 to May 2018 from the Lagos State Ministry of Health.

We omitted 10.1% of the forms based on our exclusion criteria, which included any LASAMBUS call that was misclassified as an RTA, any that were not in the study time frame, or any that were intervention forms in which the first and second pages of the form did not pertain to the same call scenario (missing pages, blank pages, etc.).

After applying our exclusion criteria, we reviewed 1352 intervention forms. Electronic supplementary material: Appendix A is a blank version of the intervention form.

We focused our analyses on the following sections:

1. · Date of Call
2. · Timing of Call
3. · Demographics of the Victim:-

• Distribution of Cases
• Intervention and Monitoring
• Trauma Prompts
• Causes for Delayed Response
• Triage Revised Trauma Score
• Remarks of the LASAMBUS Crew

To determine the outcomes of the calls received, we reviewed the "Remarks" section of the forms, which was written as a narrative.

We categorized the responses into five outcomes:

• Addressed Crash.
• No Crash (False Call).
• Crash Already Addressed.
• Did Not Respond.
• Other.

We further categorized certain outcomes based on common findings.

The forms were handwritten and while we acknowledge the possibility that forms could have been illegible, we did not encounter any illegible forms.

An electronic version of the LASAMBUS form was created to manage study data using the REDCap electronic data capture tool.

To this form, we added the Outcomes section, a second Trauma Prompts section, and a second Causes for Delay section.

The latter two sections were created to account for those forms that had a specific trauma prompt or cause for delay mentioned in the "Remarks" but were not appropriately marked in the respective sections of the intervention forms.

Since we were able to accurately identify these, we combined the data from the form along with what should have been marked initially for both the Trauma Prompts section and the Causes for Delay section for all subsequent analyses.

Response Time was defined as the difference between when the call was received and when LASAMBUS arrived at the RTA site.

We encountered some missingness in the data concerning our response time analyses.

We employed a pairwise deletion analysis technique to account for those observations that only had a call received time or a time when LASAMBUS arrived at the RTA site, for which we could not calculate a response time.

We were able to successfully calculate a response time in 82.6% of cases. Stata 15 was used to conduct descriptive statistical analysis and logistic regression analysis where α = 0.05. Bivariate analyses were conducted to assess the association between Causes for Delay and each Outcome.

Multivariate regression analyses evaluated the relationship between significant Causes for Delay and all Outcomes, and the relationship between Response Time and all outcomes.

RESULTS

LASAMBUS received 1352 Road Traffic Accident calls between December 2017 and May 2018 with an average of 226 calls per month.

The median age of the RTA victims was 34.0 years (SD 12.0) and the majority (73%) were male.

The average response time of each LASAMBUS call was 17.0 min (7–60 min). We were able to ascertain the outcome of every call, as there were no illegible forms.

LASAMBUS only addressed 37.1% of the calls that they received (Outcome I). Outcome II: No Crash (False Call) and Outcome III: Crash Already Addressed represented almost 50% of the call outcomes.

We found common responses in these categories that we further coded into subcategories.

Outcome II: No Crash (False Call) defined calls in which no crash was sighted, with or without witness corroboration.

Only 9.4% of the false calls had witness corroboration. Within Outcome III: Crash Already Addressed, the most common sub-category was "Unknown" (81.9%), in which the only description LASAMBUS gave was "crash was already addressed".

This was followed by "Responded to by Police" (3.1%) and "Self-Evacuated" (2.7%).

"Miscellaneous" responses for Outcome III included "attended to by LASEMA" and "attended to by LRU".

Within Outcome IV: Did Not Respond, "crew was asked to be on standby" represented 41.4% of the calls. "Miscellaneous" responses included "no fuel" and "no ambulance available".

Within Outcome V: Other, "found RTA, no injuries" (36.5%), and "found RTA, victim already died" (26.5%) accounted for over half of the responses.

STATEMENT OF NEED

With the above research and findings, it's very clear that our citizens in Lagos have limited access to prompt emergency medical services and inadequate or lack of prehospital medical care in the majority of the out sketch of areas of Lagos state, as well as basic medical skills and knowledge needed to save lives during an occurrence of the emergency prior the arrival of advanced life support caregivers or definitive emergency room intervention.

They are mostly from low-income households, and the neighborhood,

in general, is very distressed.

Due to the high volume of preventable death rate in the prehospital environments and the community generally occurring daily as the percentage keep going higher due to increase in population.

Lagos is also known as the most populous state in Nigeria with over 21million citizens, though this figure is debatable.

We have an affordable, reliable, efficient and intensive prehospital medical care service that is known by few citizens in Lagos already, but we need more resources to reach more of our citizens in other to curb or further reduce the occurrence of preventable death rate as well as equipping them with adequate knowledge and skills needed by embarking on First Aid and CPR Training.

Please help us save our people.

According to African Research Review showed that about 65% of Nigerian citizens are poor, which has contributed tremendously to their accessibility and affordability of good emergency medical services for improved health performance.

In Lagos state, the figure rises to 76% of low-income citizens which is depriving them to afford portable and good quality emergency medical care. These are the trends that the citizens in our state must be able to overcome.

THEORETICAL FRAMEWORK

Emergency Medical Services (EMS) is defined as the system that organizes all aspects of care provided to patients in the prehospital or out of the hospital environment.

Hence, emergency medical service is a critical component of the healthcare systems, and it's necessary to improve outcomes of injuries and other time-sensitive illnesses such as cardiac arrest.

Still there exists a substantial need for evidence to improve our understanding of the capacity of such systems as well as their strengths, weaknesses, and priority areas for establishment in our communities or states.

The aim was to develop a tool for the implementation of portable and affordable prehospital emergency medical services using the Universal Health Coverage system framework.

Relevant literature searches, journals, and expert consultation helped identify variables describing system capacity, outputs, and goals of prehospital emergency medical services.

Those were organized according to the healthcare systems framework and a multipronged approach is proposed for data collection including the use of qualitative and quantitative methods with triangulation of information from important stakeholders, direct observation, and policy document review.

The resultant information is expected to provide a holistic picture of the action of emergency medical services and develop key recommendations for emergency medical service systems in real establishment and smooth-running. Injuries and other time-sensitive related illnesses such as stroke, cardiac arrest, myocardial infarction, and obstetrics emergencies among others are significant contributions to preventable and premature mortality and disability in low and middle-income countries such as Nigeria.

The majority of such early deaths from time-sensitive conditions are the result of inaccessibility prehospital care, unavailability of transport, lack of life-saving skills, and interventions by the bystanders or relatives among others. Patients may need to be transported several kilometers to reach a health care facility in Nigeria, with up to 80% of them walking or been carried by their relatives.

Emergency medical services may encompass local, regional, or international systems for optimal delivery of prehospital care, play a critical role in improving the outcomes of both acute diseases and acute exacerbations of chronic illnesses.

The evidence shows that lack of prehospital care negatively affects the outcomes of medical and trauma emergencies; while the availability of prehospital care causes a 25% reduction rate in trauma-related mortality alone, with larger cumulative effects when safe transports are combined with prompt facility-based emergency care.

Generally speaking, patients requiring prehospital care are planned or intended to be transported to the hospital for further treatment, whereas in "out-of-hospital" emergency care such as intent or planning may be absent.

Apart from being a common resource for a variety of medical conditions, Emergency Medical Services is also the foundation for effective disaster response and management of mass casualty incidents.

World Health Organization's Universal Healthcare Coverage system framework.

This framework captures essential emergency care functions at the scene of injury or illness, during transport, and through to an emergency room in the hospital and early inpatient care due to pre-arrival notification.

The organization and provision of emergency medical services vary from country to region.

The model of prehospital care would be described in the literature from Low and middle-income countries which Nigeria is part of.

LITERATURE REVIEW

The true scope of emergency medical services in Nigeria’s delivery of prehospital care and the proportion of need being met remain known physically and socially.

A recent landscape analysis revealed that less than 5 states in Nigeria have a functioning emergency medical services in place, with limited capacity to respond, evaluate, treat, and safely transport patients.

Meeting a broad spectrum of medical needs requires innovative thinking, planning, and adaptation, particularly in the areas with fewer resources.

This issue was highlighted by the World Health Organization in a 2007 resolution calling on national governments to strengthen emergency care globally in partnership with the World Health Organization.

Despite several studies on emergency medical services readiness, there is less evidence on the true capacity, performance, and sustainability of prehospital care.

Thorough knowledge of infrastructure, service delivery, coverage, and information flow is required to determine if the prehospital care system is sufficient to meet the health needs of a community.

There have been some efforts towards defining core elements, performance indicators, and gaps in services delivery for emergency medical services and prehospital trauma care.

Some studies have addressed facility-based assessment based on World Health Organization guidelines to identify gaps ad prioritize areas for establishment in acute care facilities.

However, there exists a need for a rapid yet comprehensive tool for the systemic establishment of sustainable prehospital emergency medical services that combines input from the policymakers, care providers, and community members.

This review describes the core elements of the emergency medical service system within the health systems framework and proposes a tool that focuses on the system-wide establishment of emergency medical services in Nigeria.

The specific objectives of this review include the following:

1. To provide a brief overview of selected instruments ad approaches to emergency medical services assessment and establishment .
2. To identify emergency medical services-related variables and core indicators that provide information according to a health systems framework, and
3. To propose an approach for the implementation of an assessment tool ad identifies sources of information for deployment in Nigeria.

Although this proposed framework covers broad components of the overall emergency medical care in Nigeria and other low and middle-income countries.

SELECT INSTRUMENTS AND GUIDELINES

There is a diverse body of published literature that covers Emergency Medical Services, prehospital care standards, and international guidelines on the prehospital trauma care systems from high-income countries to low and middle-income countries.

The following section reviews the key features of a select number of these guidelines and assessment instruments.

The American College of Surgeons Committee on Trauma established guidelines for the care of injured patients in the form of resources for optimal trauma care, which was first published in 1976 and is the foundation of the trauma center verification and certification process in the USA.

This policy document is a comprehensive resource inventory for high-quality facility-based trauma care that emphasizes the concept of an “inclusive” trauma system with well-defined assessment, verification, and performance improvement measures for trauma centers.

These standards are difficult to achieve and maintain in many low- and medium-income countries settings like Nigeria, however, and despite a public health model, this resource document narrowly focuses on trauma care as opposed to covering all emergencies.

The World Health Organization guidelines for essential trauma care, developed in collaboration with the International Association for the Surgery of Trauma and Surgical Intensive Care in 2004, are directed towards improving facility-based trauma care and cover the knowledge, skills, and equipment required to deliver appropriate trauma care.

The guidelines include a series of resource tables for essential trauma care that detail the human and physical resources that should be in place at each health facility, ranging from rural health posts to hospitals staffed by general practitioners and specialists, to tertiary care centers.

These guidelines also account for varying resource availability across the spectrum of low-medium income countries.

The document includes recommendations for training, performance improvement, and hospital inspection to optimize care of the injured but does not address other medical problems or common emergencies.

The World Health Organization guidelines for pre-hospital trauma care, published in 2005, focus on standards of pre-hospital trauma care systems by providing a resource matrix with essential, desired, and possible components of knowledge, skills, equipment, and supplies, each classified according to the level of pre-hospital providers.

Since the key focus of these guidelines is to promote the development of pre-hospital trauma systems, its scope also extends to important system-level elements such as organization and oversight, coordination, documentation of care, and ethical and legal issues pertinent to trauma care. Generally, the World Health Organization guidelines for pre-hospital trauma care stipulate the foundation for general emergency care and could be used for a broader range of emergencies, albeit with less specificity.

The most recently developed World Health Organization emergency care system assessment tool has been designed to help policy-makers and planners assess a national or regional emergency care system, identify gaps, and set priorities for system development.

It is a survey-based tool that can facilitate priority setting through convened external assessment.

This tool is also the most relevant to our study goals and objectives; however, the information input is largely dependent on the knowledge of key informants responding to survey questionnaires or in the setting of a convened consensus exercise.

The survey does not include input from patients or customers of Prehospital Emergency Medical Services and hence allows gaps in the assessment of access, quality, and responsiveness of services to remain.

CONCEPTUAL FRAMEWORK FOR THE EMERGENCY MEDICAL SERVICES ASSESSMENT

To encompass a holistic picture of Prehospital Emergency Medical Service in a community or geographical locale, the “Framework for Action for strengthening health systems” proposed by the World Health Organization provides essential domains of a system-based assessment.

The World Health Organization health systems framework is designed to capture and quantify building blocks (inputs), outputs, and long-term outcomes. While long-term outcomes and impact of interventions may be difficult to measure in a cross-sectional assessment, the framework provides a guide for the inclusion of important indicators.

This conceptual framework is supposed to rely upon the inter-relatedness of;

(i) health service delivery model

(ii) well-performing, trained Prehospital Emergency Medical Services’ health workforce which includes mainly the Paramedics

(iii) a well-functioning communication system that includes a Universal Access Toll-Free Number (UATFN) and a dispatch system; such as the existing 112 in Nigeria

(iv) access to life-saving medications, equipment, procedures, and expertise at the scene, in transport, and during transfer;

(v) appropriate use of technology by the Prehospital Emergency Medical Services staff and administrators such as Automated External Defibrillator

(vi) financing mechanisms to safeguard the sustainability of the Prehospital Emergency Medical Services, such as insurance coverage, grants, and incentives, etc.; and

(vii) leadership and governance that provide regulatory bodies as well as legal and policy frameworks.

Building on the previous work, identification of variables and indicators of pre-hospital care could stipulate comprehensive information on inputs, processes, outputs, and desired outcomes of Prehospital Emergency Medical Services.

CONCLUSION

While the Road Traffic Accident’s mortality rate in Nigeria is increasing annually, Lagos is especially affected as the most populous state in Nigeria.

Lagos State Ambulance Service LASAMBUS, Lagos State Emergency Management Agency LASEMA and Lasema Response Unit LRU are all facing various obstacles in attending to Road Traffic Accidents and their current response rate is alarming due to delayed response time, which makes them be playing parts in the increasing mortality rates.

Focusing attention on the need for establishing a self-sustainable and affordable private emergency medical service for all citizenry as well as equipping them with adequate knowledge and skills needed to save lives before the arrival of the advanced life support providers as heavy traffic congestion may slow down the response time during an emergency.

From the research, it’s very clear that the Lagos State government’s agency for managing emergencies is still unable to attend to over 58% distress call from the citizens which is even enough for springing up of Medevac Nigeria Limited to bridge the gap in accessing quality prehospital healthcare through an affordable emergency medical services to curb or slow down the mortality rate in our society.

A sustainable Universal Healthcare Coverage for all is very important and achievable, even in populated states like Lagos state to decrease the mortality rate and improve the outcome of good prehospital care that has been heavily linked with Lagos state government.

To achieve this, a collective effort has to be made by LASAMBUS, the Lagos Ministry of Health, and a private establishment to provide the highest quality emergency medical services like Medevac Nigeria Limited.