Research

Service Pillar

We foster collaborations and partnerships to promote and encourage the study, research and advancement of the science and practice of emergency medical care in Kenya.

 

6

Peer-Reviewed Publications

5

Scientific Posters

5

Reports

Research in Action

Peer-reviewed Publications

Lee JA, Wachira BW, Kennedy J, Asselin N, Mould-Millman NK. Utilisation of WhatsApp for Emergency Medical Services in Garissa, Kenya.

Afr J Emerg Med. 2024 Mar;14(1):38-44.

Abstract

Garissa county, Kenya is a geographically large county with a mobile pastoralist population that has developed a method for emergency medical services (EMS) coordination using the WhatsApp communication platform. This work was based on a site visit, to better understand and describe the current operations, strengths, and weaknesses of the EMS communication system in Garissa. The use of WhatsApp in Garissa county seems to work well in the local context and has the potential to serve as a cost-effective solution for other EMS systems in Kenya, Africa, and other LMICs.

Wanjiku, G., Dreizler, L., Wu, S. et al. Utility of hand-held ultrasound for image acquisition and interpretation by trained Kenyan providers. 

Ultrasound J 15, 12 (2023).

Abstract

Background: Point-of-care ultrasound (POCUS) plays a prominent role in the timely recognition and management of multiple medical, surgical, and obstetric conditions. A POCUS training program for primary healthcare providers in rural Kenya was developed in 2013. A significant challenge to this program is the acquisition of reasonably priced ultrasound machines with adequate image quality and the ability to transmit images for remote review. The goal of this study is to compare the utility of a smartphone-connected, hand-held ultrasound with a traditional ultrasound device for image acquisition and interpretation by trained healthcare providers in Kenya.

Methods: This study took place during a routine re-training and testing session for healthcare providers who had already received POCUS training. The testing session involved a locally validated Observed Structured Clinical Exam (OSCE) that assessed trainees’ skills in performing the Extended Focused Assessment with Sonography for Trauma (E-FAST) and focused obstetric exams. Each trainee performed the OSCE twice, once using a smartphone-connected hand-held ultrasound and once using their notebook ultrasound model.

Results: Five trainees obtained a total of 120 images and were scored on image quality and interpretation. Overall E-FAST imaging quality scores were significantly higher for the notebook ultrasound compared to the hand-held ultrasound but there was no significant difference in image interpretation. Overall focused obstetric image quality and image interpretation scores were the same for both ultrasound systems. When separated into individual E-FAST and focused obstetric views, there were no statistically significant differences in the image quality or image interpretation scores between the two ultrasound systems. Images obtained using the hand-held ultrasound were uploaded to the associated cloud storage using a local 3G-cell phone network. Upload times were 2-3 min.

Conclusion: Among POCUS trainees in rural Kenya, the hand-held ultrasound was found to be non-inferior to the traditional notebook ultrasound for focused obstetric image quality, focused obstetric image interpretation, and E-FAST image interpretation. However, hand-held ultrasound use was found to be inferior for E-FAST image quality. These differences were not observed when evaluating each E-FAST and focused obstetric views separately. The hand-held ultrasound allowed for rapid image transmission for remote review.

Nyamu N, Sugut J, Mochache T, Kimeu P, Mukundi G, Ngugi D, Njonjo S, Mustafa A, Mbuvi P, Nyagaki E, Kironji G, Wanjiku G, Wachira B.

Crit Care Clin. 2022 Oct;38(4):839-852. doi: 10.1016/j.ccc.2022.06.012.

 

One of the major obstacles to delivering effective emergency care in developing countries is a lack of adequate training. Facility-oriented, simulation-based emergency care training programs developed locally present an opportunity to improve the quality of emergency care in low- and middle-income countries. We describe the development and implementation of the emergency care course in Kenya and the strengths, weaknesses, opportunities, challenges, and recommendations for locally developed facility-oriented simulation-based emergency care training.

Lee, J.A., Armes, L. & Wachira, B.W.

Int J Emerg Med. 2022 Jun 28;15(1):30. doi: 10.1186/s12245-022-00432-6.

Background: Road traffic injuries are a large and growing cause of morbidity and mortality in low- and middle-income countries, especially in Africa. Systematic data collection for traffic incidents in Kenya is lacking and in many low- and middle-income countries available data sources are disparate or missing altogether. Many Kenyans use social media platforms, including Twitter; many road traffic incidents are publicly reported on the microblog platform. This study is a prospective cohort analysis of all tweets related to road traffic incidents in Kenya over a 24-month period (February 2019 to January 2021).

Results: A substantial number of unique road incidents (3882) from across Kenya were recorded during the 24-month study period. The details available for each incident are widely variable, as reported and posted on Twitter. Particular times of day and days of the week had a higher incidence of reported road traffic incidents. A total of 2043 injuries and 1503 fatalities were recorded.

Conclusions: Twitter and other digital social media platforms can provide a novel source for road traffic incident and injury data in a low- and middle-income country. The data collected allows for the potential identification of local and national trends and provides opportunities to advocate for improved roadways and health systems for the emergent care from road traffic incidents and associated traumatic injuries.

Wanjiku GW, Bell G, Wachira B.

BMC Health Serv Res. 2018; 18: 607.

Background

A novel point-of-care ultrasound (PoCUS) training program was developed to train rural healthcare providers in Kenya on the Focused Assessment with Sonography for Trauma (FAST), thoracic ultrasound, basic echocardiography, and focused obstetric ultrasonography. The program includes a multimedia manual, pre-course testing, 1-day hands-on training, post-testing, 3-month post-course evaluation, and scheduled refresher training. This study evaluates the impact of the course on PoCUS knowledge and skills. Competency results were compared based on number of previous training/refresher sessions and time elapsed since prior training.

Methods

Trainees were evaluated using a computer-based, 30 question, multiple-choice test, a standardized observed structured clinical exam (OSCE), and a survey on their ultrasound use over the previous 3 months.

Results

Thirty-three trainees were evaluated at 21 different facilities. All trainees completed the written exam, and 32 completed the OSCE. Nine trainees out of 33 (27.3%) passed the written test. Trainees with two or more prior training sessions had statistically significant increases in their written test scores, while those with only one prior training session maintained their test scores. Time elapsed since last training was not associated with statistically significant differences in mean written test scores. Mean image quality scores (95% confidence interval) were 2.65 (2.37–2.93) for FAST, 2.41 (2.03–2.78) for thoracic, 2.22 (1.89–2.55) for cardiac, and 2.95 (2.67–3.24) for obstetric exams. There was a trend towards increased mean image quality scores with increases in the number of prior training sessions, and a trend towards decreased image quality with increased time elapsed since previous training. Forty percent of trainees reported performing more than 20 scans in the previous 3 months, while 22% reported less than 10 scans in the previous 3 months. Second and third trimester focused obstetric ultrasound was the most frequently performed scan type. Frequency of scanning was positively correlated with written test scores and image quality scores.

Conclusion

This novel training program has the potential to improve PoCUS knowledge and skills amongst rural healthcare providers in Kenya. There is an ongoing need to increase refresher/re-training opportunities and to enhance frequency of scanning in order to improve PoCUS competency.

Nicholson B, McCollough C, Wachira B, Mould-Millman NK.

Afr J Emerg Med. 2017 Dec;7(4):157-159. doi: 10.1016/j.afjem.2017.06.002. Epub 2017 Aug 8.

Background: Over the past twenty years, Kenya has been developing many important components of a prehospital emergency medical services (EMS) system. This is due to the ever-increasing demand for emergency medical care across the country. To better inform the next phase of this development, we undertook an assessment of the current state of EMS training in Kenya.

Methods: A group of international and Kenyan experts with relevant EMS and educational expertise conducted an observational qualitative assessment of Kenyan EMS training institutions in 2016. Three assessment techniques were utilised: semi-structured interviews, document review, and structured observations. Recommendations were reached through a consensus process amongst the assessment team.

Results: Key findings include: (i) No national or state-level policy exists that establishes levels of EMS providers or expected fund of knowledge and skills; (ii) Training institutions have independently created their own individual training standards; (iii) Training materials are not adapted for the local context; (iv) The foundation of basic anatomy and physiology education is weak; (v) Training does not focus on symptom- or syndrome-based complaints; (vi) Students had difficulty applying foundational classroom knowledge in simulations and clinical encounters; (vii) There is limited emphasis on complex critical thinking.

Discussion: Standardisation of training is needed in Kenya, including clearly defined levels of providers and expected learning outcomes. A nationally standardised EMS provider scope of practice may also help focus EMS education. Instructors must reinforce basic anatomy and physiology amongst all trainees to establish a robust foundation, then layer on field experience before trainees receive advanced training. Training graduates should be EMS providers who approach patient care with high-order symptom- or syndrome-based critical thinking. While these recommendations are specific to the Kenyan EMS environment, they may have wider applicability to other developing EMS systems in resource-limited settings.

Bell G, Wachira B, Denning G.

Afr J Emerg Med. 2016 Sep; 6(3): 132–137.

Introduction

Ultrasound is an effective and affordable clinical diagnostic tool highly attractive for use in low and middle income countries (LMICs), but access to training programs in these countries is limited. The objective of our study was to develop and pilot a program for healthcare providers in Kenya in the use of point-of-care ultrasound.

Methods

Trainees were recruited in district hospitals for participation in three all-day workshops held every 3–5 months from September 2013 through November 2014. Prior to the initial workshop, trainees were asked to study a training manual, and a knowledge test was administered. Ultrasound-credentialed emergency physicians provided brief didactic lessons then hands-on training for eFAST and obstetric training. This was followed by an observed assessment of scanning image quality (IM) and diagnostic interpretation (IN).

Results

Eighty-one trainees enrolled in four initial training sessions and 30 attended at least one refresher session. Among those trainees who attended refresher sessions, there was an increase in the proportion passing both the knowledge and practical tests at the follow-up, as compared to the initial session. Overall, mean practical skill scores also trended toward an increase over time, with a significantly higher mean score in November 2014 (2.64 + 0.38, p = 0.02) as compared to March 2014 (2.26 + 0.54), p < 0.05. Pre-workshop preparation evolved over time with the goal of maximizing trainee readiness for the hands-on course. A strong correlation was observed between knowledge and practical skill scores illustrating the importance of pre-workshop training.

Conclusions

Our pilot workshop showed promise in promoting knowledge and practical skills among participants, as well as increasing use in patient care. Results also suggest that refresher training may provide additional benefits for some participants. These findings provide a strong rationale for expanding the training program and for measuring its clinical impact.

Scientific Posters

 

Presented as an e-Poster presentation at the Society for Academic Emergency Medicine Conference (May 2021).

Presented as a Poster presentation at the Emergency Medicine Society of South Africa (EMSSA) International Conference (Nov 2019)

Reports

According to the WHO, oxygen therapy is recommended for all severe and critical COVID‐19 patients. The ability to boost capacity to deliver oxygen therapy is the cornerstone of the overall approach to managing the COVID‐19 outbreak and it has implications for the functioning of the entire system.

In a recent survey of emergency care centers across Kenya, over 30% of the facilities did not have a regular supply of oxygen. Close to 90% of those with oxygen did not have piped oxygen in the emergency department and delivered oxygen directly from the tanks to the patient.

Thanks to the support of donors and working in conjunction with the county governments, EMKF installed oxygen gas manifolds in various County Referral Hospital Emergency Departments between April and June 2020.

For many people in Kenya and across the world, the emergency department (ED) is the primary point of access to the health system. An increasing number of patients with acute disease currently present to EDs across Kenya. This is due to the rising incidence of non-communicable diseases (NCDs) (such as

cancer, diabetes and hypertension), mental illness and trauma (largely secondary to road traffic injuries) in the background of an already existing large burden of communicable diseases.

The goal of Project 47 which began in May 2018, has been to assess the current state and locations of emergency departments in emergency care centres across the 47 counties in Kenya, identify gaps, and set priority actions for use by County Governments, planners and partners as a roadmap toward
universal emergency care coverage. Emergency Care Centres are defined as public facilities (including NGOs and FBOs) that are open 24 hours a day and have a functioning theatre.

This assessment, conducted by external EMS experts with expertise in African and international EMS systems and EMS education, reports several key findings and offers important recommendations to help standardise and enhance the quality of training in Kenyan prehospital care. In brief, the key recommendations are as follows:

  1. A standard Kenyan EMS scope of practice (document and policy) is needed that defines levels (i.e. tiers or cadres) of EMS providers and delineates all knowledge and skills required to practice as a prehospital provider at the given level.
  2. A standard for EMS training should be developed and implemented to help ensure high quality and uniformity in EMS training across institutions, and alignment with the Kenyan EMS scope of practice.
  3. There should be a transition from over-reliance on non-Kenyan curricula and training content, to more Kenya-specific materials and content targeted to the local burden of disease, healthcare system, and available resources. External reference texts/material can function as a guide for initial training initiatives and provide coarse structure, but training content should be edited as much as possible to reflect local needs.
  4. The EMS training culture should shift away from diagnosis-based training to syndrome or symptom-based training.
  5. EMS trainees could greatly benefit from stronger foundational didactic classroom-based education (classroom education) at the Basic (EMT) level with a specific focus on clinically relevant basic anatomy and physiology. This should be limited to the knowledge and basics directly relevant to their scope of practice. 
  6. To improve foundational clinical training in emergency care, all trainees should first achieve competencies and attain adequate field experience at a basic (EMT) provider level, before receiving additional training to higher qualifications (e.g. Intermediate Life Support (ILS) or Advanced Life Support (ALS).
  7. Higher-order and critical thinking skills need to be developed, by integrating basic knowledge and skills into real-world clinical scenarios, which should be heavily woven into all aspects of EMS training programs.

Resources

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