A total of 11 key informants provided information across three facilities.
Facility characteristics
The tertiary hospital served the nation’s entire population, while each regional hospital had a smaller catchment population of approximately 250,000. All hospitals reported capacity to provide emergency care 24 hours per day. Hospitals were staffed by providers who were in-unit during opening hours; nurses remained in units overnight while higher-level providers were on-call for emergencies but off-campus. Two hospitals reported that their emergency care areas were staffed only with rotating providers assigned for periods of approximately one month, and did not have staff permanently assigned to emergency care areas. All sites reported having at least one operating theatre that was always available for emergency operations (Table 2).
Table 2: Facility metrics at referral hospitals in Eswatini.
Metric
|
Tertiary Hospital
|
Regional Hospital 1
|
Regional Hospital 2
|
Inpatient beds
|
500
|
100
|
175
|
Inpatient admissions (per year)
|
5,000
|
3,500
|
6,200
|
Operating theatres available 24 hours a day, 7 days a week
|
1
|
2
|
1
|
Emergency operations (per year)
|
600
|
1,300
|
800
|
Emergency visits (per year)
|
37,000
|
19,500
|
75,000
|
Patients arriving by ambulance
|
20%
|
17.5%
|
20%
|
All hospitals maintained two distinct areas for the delivery of emergency care. One was a casualty area for the treatment of injuries and the other an emergency area within the general outpatient department (OPD). Casualty and OPD areas were physically separated by some distance across campuses at two hospitals. In combination, these areas were able to provide 24-hour emergency care services at each facility. For the purposes of responses reported below, we report on whether services could be performed in either of the above mentioned emergency care areas.
Two facilities had dedicated triage areas (Appendix 1). The tertiary hospital was the only facility with a dedicated resuscitation area. All facilities noted challenges with obtaining medications; two receive key medications from pharmacy when needed. Lack of equipment was noted in all facilities.
All hospitals had general laboratories with multiple diagnostic laboratory tests available, including full blood count and glucose testing. However, many tests, including rapid HIV testing, were generally unavailable due to reagent stockouts, and reporting of results not timely. Blood banks were located in all three hospitals.
Human resources
All facilities reported receiving a wide range of medical and surgical cases (Appendix 2). Training deficits were noted by al hospitals; these included training related to critical trauma and airway interventions, and neonatal care. At all facilities, patients presenting with obstetric and gynaecological (OB/Gyn) complaints were ultimately sent to the maternity ward. At two facilities, an on-call OB/Gyn provider was used to assist with emergent cases prior to transfer to the ward. On call speciality services varied across sites.
Clinical services
None of the facilities had clinical protocols (e.g. those for managing asthma, sepsis, DKA, etc.) (Appendix 3). There were no protocols in place for communication of critical lab results, patient or staff safety, or emergency response. Additionally, there were no protocols for infection control measures such as isolation of infectious patients or management of hazardous waste. Emergency care areas had some safety features in place, but most were not maintained. Protocols for flow through emergency care areas, including triage, patient disposition, and communication, did not exist. Two emergency care areas had dedicated spaces for triage, and all were able to obtain vital signs on patients on arrival. No formal triage systems exist.
Signal functions
All hospitals were able to assess vital signs in emergency care areas, but the two regional hospitals were often not able to obtain pulse oximetry due to lack of equipment (Appendix 4).
For airway interventions, all hospitals were able to administer oxygen and bronchodilator therapy when equipment was functional and available. Only the tertiary hospital could always perform manual manoeuvres to open an airway as well as bag-valve-mask ventilation; regional hospitals were often limited in performing these functions due to lack of equipment and training. More advanced airway procedures such as nasopharyngeal/oropharyngeal airways, supraglottic airway device placement, and endotracheal intubations, as well as invasive and non-invasive mechanical ventilation, were rarely performed in any facility due to lack of training and equipment. Most providers in all three hospitals had the training and skills needed to perform needle thoracostomies or place chest tubes; however, absent equipment was often a barrier to provision.
Circulatory emergencies were almost always able to be managed on a basic level at all facilities. Providers in all hospitals were consistently able to administer oral rehydration, establish intravenous (IV) access, and administer IV fluids, though all faced challenges in adjusting IV fluids for cases of malnutrition or severe anaemia. The tertiary hospital and one regional hospital were sometimes able to obtain central venous access; none could provide intraosseous access or venous cutdown due to a lack of training. Pelvic binders were not used in any emergency care areas due to absent equipment and provider knowledge; these same barriers also limited the provision of safe blood transfusions. Thrombolytics were only available at the tertiary hospital. Electrocardiograms and point-of-care ultrasound were often unavailable due to absent equipment and lack of training for interpretation. For the same reasons, external defibrillation, cardioversion, pericardiocentesis, and external cardiac pacing were generally not available in any of the facilities.
All emergency care areas could assess patients using a mental status examination and perform basic neurologic interventions such as checking and managing blood glucose levels, administering benzodiazepines, managing extreme temperatures and providing physical restraint. Lumbar punctures were performed regularly at the tertiary emergency care area and one regional hospital emergency care area: at the other, they were limited by trained provider availability. Procedural sedation was not typically performed in emergency care areas and instead was reserved for the ward or operating theatre. Locally appropriate antidotes were rarely administered at any facility due to stockouts.
IV antibiotics for sepsis were usually available in all emergency care areas; two could administer IV vasopressors. The tertiary hospital was able to perform diagnostic paracentesis and all three facilities could perform minor surgical techniques for source control.
Traumatic injuries, which were seen exclusively in casualty units, were also managed well at a basic level. Providers in all emergency care areas were generally able to perform initial wound care and immobilisation of fractures, with most facilities being able to perform closed reductions of fractures and dislocations as well as immobilising the cervical spine. Antibiotics and opioids were always administered for open fractures when in stock. Staff in all emergency care areas were able to place urinary catheters, perform external haemorrhage control, and perform bleeding control with tourniquets. Packing and suturing to control bleeding could be done in two facilities and was only limited in the third due to stock outs. Adrenaline could be administered at all hospitals. None of the facilities were able to apply three-way dressings for sucking chest wounds or perform fasciotomies or escharotomies in emergency care areas: these procedures were typically performed in the operating theatre.
All hospitals were able to perform assisted vaginal deliveries in emergency care areas, if needed. Uterotonic drugs were unavailable, and neonatal resuscitation efforts were limited due to equipment, training, and personnel.