Agents of Change for Emergency Medicine in Africa: Nurses!

Dr. Jennifer Whitfield Bellows

This week found the GECI faculty in Kigali, Rwanda at the African Federation of Emergency Medicine Conference. Despite having been to several international EM conferences in the past, I never fail to be humbled and honored to meet the EM physicians that are on the leading edge of our specialty in Africa, who advocate for their patients to receive high quality acute care even as our specialty still struggles to receive recognition and resources.  

 This time, however, it was a different kind of champion that impressed and humbled me. Nurses. 

Developing and implementing emergency medicine systems - the package of advanced triage processes, provision of essential resources, and training of the staff working in emergency departments – does not happen overnight. A remarkable investment is needed for success: to not only implement the processes but to continue to teach and assess them, and to make sure that they remain in place even as staffing, patient volumes, and resources change. Success relies on months or even years of constant monitoring and re-training. Thus a unique kind of local champion is necessary: a person embedded in the community served by this emergency department, who works there every day and intimately understands the cultural and social nuances that effect patient care. 

You know who does that best?  Yep. Nurses. 

Health care human resource shortages are endemic to many low-resource hospitals; and oft-quoted statistic is the alarmingly low ratio of physicians to 100,000 people. Nurses are also in short supply but thankfully not in the same critically low levels as doctors. By necessity, they often step in to provide duties normally ascribed to doctors, a phenomenon known as “task – shifting”.  

As we saw this week, EM systems development is no exception. Nurses have been the leaders creating and maintaining functional, high quality emergency departments, with results that are nothing short of extraordinary. 

Halima Adam and Violet Mirembe are nurses in the Emergency Department at Mubende Regional Hospital in Kampala, Uganda. From 2016 to 2018, they implemented a comprehensive overhaul of the emergency ward including the following:

1.     Got providers trained in the WHO 5 day Basic Emergency Course.

2.     Defined clear roles for providers.

3.     Instituted a triage system.

4.     Ensured basic essential equipment and medications were available and staff was trained on their use. 

5.     Used pathways and checklists to standardize patient care and ensure safe handoffs. 

As a result, massive improvements were seen. From 2015 to 2018: 

1. Vitals were taken on emergency patients 80% of the time, from 30% in 2015.

2. Essential equipment and medicine stocked 70% of the time, up from 40% in 2015.

3. Mortality dropped in their surgical unit (where the ED is located) by an incredible 50%!

Success of this magnitude is extraordinary, and it is a testament to the dedication, resilience and leadership of these nurses to providing excellent care to their patients. I am in awe. 

Every medical resident has a story about how, at least once (or in my case, like once a week) a nurse saved their patient - by catching an error or recognizing when one is decompensating. If Violet and Halima are any indication, nurses that step in and lead their hospitals through emergency care system reform will save countless more.