Implementation of Emergency Clinical Pathways to Improve Patient Outcomes in Zambia

In March 2018, a team of three emergency medicine residents (Kimberly Hill, Chelsea McCullough, and Jennifer Zhan) and one attending physician (Dr. Jennifer Bellows) traveled to Zambia to begin their journey in implementing clinical care pathways to advance emergency care. The team visited five hospitals and engaged in discussions with local staff as well as officials within the Zambian Ministry of Health with regards to feasibility and applicability of the emergency clinical care pathways that GECI has developed over the past few years.

The story began two years before, when the University of Colorado Global Emergency Care Initiative (GECI) launched a study to develop and implement clinical pathways that would provide a systematic approach to early resuscitation and stabilization of acutely ill patients. The GECI team constructed a list of empirically derived chief complaints from multiple African countries. From those lists, the most life-threatening complaints were extracted, and clinical pathways that were consistent with best practice emergency care guidelines - described in the African Federation for Emergency Medicine’s Handbook on Acute and Emergency Care - were developed. The pathways were organized with consideration of resource levels at multiple different types of hospitals common to low and middle-income countries. They were also made available to providers via a free application available on smartphones, allowing for rapid electronic access using the proven AgileMDä platform.

This trip to Zambia represented the initial fact-finding mission and a foundation for the pilot study to be performed in early 2019. The team visited five facilities and met with local health care providers at each site. These facilities represented a spectrum of facility tiers ranging from primary to tertiary levels of care and all completed the World Health Organization’s Basic Emergency Care Course, which provided an essential foundation of emergency care. The team presented overall project aims and five pertinent adult and paediatric clinical care pathways for review: asthma, sepsis, seizure, cough with fever, and blunt and penetrating trauma. A pre-

determined list of questions regarding the facility, the structure of the local emergency unit (EU), and available staff was then answered by the highest ranking provider available with the goal of informing future implementation strategies and site selection for the upcoming pilot study. Clinicians were also asked to provide feedback on the pathways with regards to applicability, feasibility and appropriateness of the selected pathways.

KasamaGeneralHospitalBlog.jpg

The team was met with tremendous enthusiasm. Zambian providers overwhelmingly agreed that the pathways would be useful in the emergency care setting and feasible to implement with current levels of training amongst emergency staff. The GECI team now prepares for a return trip in January 2019 to begin the pilot study, where they will select two hospital sites to pilot pathway implementation and data collection on process and clinical patient outcomes as well as pathway utilization by providers.

Additionally, the team facilitated the World Health Organization’s Basic Emergency Care (BEC) course at Chongwe District Hospital. The BEC course is clinical training aimed at frontline providers (doctors, nurses, clinical officers) who by necessity provide emergency care at their facilities, but have received little or no formal training in the field. Chongwe District Hospital is the only hospital in the town of Chongwe, serving a catchment area of 200,000 residents. This is the fifth facility in Zambia where the BEC Course has been taught. The course now spans three provinces and includes a total of 146 participants.

ZambiaHappyGroupBlog.jpg

This project was initiated and driven by GECI and the emergency medicine residents at Denver Health who are passionate about advancing emergency care on a global level. The clinical pathways are the culmination of two years of teamwork and collaboration between GECI, the African Federation for Emergency Medicine, AgileMDä, and GECI’s generous donors. As Dr. Jennifer Zhan describes, “This is the beginning of something great. Not only does this project have a tremendous personal impact, it has the capability to influence emergency care in Zambia and potentially the world. That keeps me ticking.”