/ 4 September 2012

Emergency care is an acute need

Proper emergency training will save lives
Proper emergency training will save lives

Although there is no question that public health programmes as well as vertical programmes targeted at specific diseases positively affect related health outcomes, they have had little effect on injuries and deaths associated with injury and emergency illness, including acute presentations of HIV/Aids, tuberculosis, malaria, haemorrhage, shock and trauma associated with childbirth.

It is important to develop systems for the delivery of emergency care to those who become ill or injured. Acute care should be a top priority, not an afterthought, for healthcare funding in sub-Saharan African countries. Establishing acute care programmes would protect and enhance investments in human lives.

There is strong evidence supporting the efficacy of acute care in a wide range of conditions as diverse as pneumonia, influenza, myocardial infarction and trauma. Many of these diseases can be treated or the risk of their occurrence mitigated with ­quality acute care. Having an effective acute care system in place allows for increased surge capacity and better patient care when man-made and natural disasters arise, reducing unnecessary morbidity and mortality and the reliance on outside relief efforts. Effective acute care helps to strengthen the health system by:

  • Increasing the efficacy of treatment for communicable diseases;
  • Reducing morbidity and mortality and providing secondary prevention for non-communicable diseases and trauma;
  • Strengthening vertical and public health programmes;
  • Providing a mechanism to perform disease surveillance or public health interventions in those who access care only episodically; and
  • Increasing community and health system preparedness for mass casualty incidents.

The number of deaths associated with acute presentations of HIV-related infections, haemorrhagic shock in childbirth and other acute aspects of diseases largely addressed through vertical programmes underscores the importance of strong acute care systems in all aspects of health delivery. Given the increasing morbidity and mortality burden from trauma, acute illness and acute exacerbations of chronic illness, health-related millennium development goals will be increasingly difficult to achieve without investing in acute care systems. These goals are to reduce childhood mortality, improve maternal health and combat the incidence of HIV, malaria and other communicable diseases.

Acute care must be easily accessible, basic emergency services should be available at all facilities and there should be an increasing breadth of services available at larger facilities. This makes services locally accessible and limits transfers to those who require specialised care.

Making acute care accessible is one challenge; making it quality care is another. Acutely ill patients must be assessed rapidly and have expedited access to essential diagnostic testing and treatments. The providers responsible for providing acute care must be physically present and dedicated entirely to acute care.

Dedicated training
An effective acute care system depends, in part, on the proper training of clinical officers who provide emergency care. Clinical officers – non-doctor, non-nurse grades of staff who receive dedicated training in selected areas of healthcare – provide most emergency care. But lacking from nearly all their curriculums is emergency care training, despite this grade of healthcare professional servicing most "casualty" areas – where they exist at all. Nursing care is similarly lacking in any form of fundamental emergency and acute care training.

Sustainable emergency care training programmes for various health providers are essential to the success of a quality acute care system. Providers of acute care must have appropriate resources available to them. The development of systems for the delivery of emergency care in regions and countries where they do not yet exist requires a multifaceted approach and the incorporation of proven solutions into resource-constrained environments. Although proofs of concept of acute care interventions exist across Africa, their effect, benefit, cost, comparative value to other health investments and contribution to overall population health remains opaque to many important decision-makers.

Local healthcare systems should be strengthened and the way leaders think about emergency care should change. It is important to involve the private sector, especially because the International Monetary Fund estimates that 60% of healthcare in sub-Saharan Africa is delivered through private mechanisms. The perceived self-interest for business and political leaders in developing acute care systems as well as the effect on the economic development of having emergency care available can be powerful ways of attracting political and financial support. Expanding quality acute care in emerging economies requires the involvement of leaders with a genuine concern for humanity.

For an acute care system to be successful, there should be support for it at both provider and administrative levels. The former includes the acute care provider and other affected clinicians in the health system and the latter local hospital leadership, national education institutions and regional and national health officials. There must be champions of acute care at each level of the health system who understand the full spectrum of benefits it can provide.

Professor Lee Wallis heads the ­division of emergency medicine in the department of interdisciplinary health sciences at Stellenbosch University­