Impact of the World Health Organization Basic Emergency Care Course in Tanzania and Uganda

Background: There is a pressing need for emergency care training in low-resource settings. We assessed the feasibility and acceptability of training front-line health care providers in emergency care with the WHO-ICRC Basic Emergency Care Course using a training-of-trainers model with local providers. Methods: Observational study of an educational intervention at four rst level district hospitals in Tanzania and Uganda. A two-day training-of-trainers course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC course, taught by the newly trained trainers, at two district level hospitals in each country. Difference between pre- and post-basic emergency care knowledge assessments and difference in pre- and post-emergency care skill condence scores were assessed. Secondary outcomes include qualitative feedback on the training from participants and trainers. Results: 59 participants completed the BEC courses. All participants were current health care workers in the selected hospitals. An additional 10 participants completed a training-of-trainers course. Knowledge assessment scores improved signicantly at all four sites with an overall 20.7 point (95%CI: 16.8 to 24.6; p <0.0001) absolute increase on a 100-point scale. Condence scores on emergency care skills also improved signicantly at all sites, 0.74 point (95%CI 0.63-0.84; p <0.0001) absolute increase on a 4-point scale. Main qualitative feedback themes were: positive reception of the sessions, especially hands-on skills; request for additional BEC trainings; request for obstetric topics; and need for more allotted training time. Conclusions: Implementation of WHO-ICRC BEC Course by locally trained providers was feasible, acceptable, and well-received at four sites in East Africa. Knowledge assessment scores and trainee condence increased signicantly at all sites. The BEC is a low-cost intervention that can improve knowledge and skill condence across provider cadres.


Background
Everyday, people seek care for health emergencies. Over 50% of mortality worldwide can be attributed to emergency medical conditions. [1] In low-resource settings, the need is particularly great: 90% of injury related deaths occur in low-and middle-income countries (LMICs) and patients in LMICs suffer the highest rates of mortality from acute complications of chronic diseases. [2,3] Overall 54% of annual deaths in LMICs could be potentially addressed by emergency care, suggesting an opportunity to improve these outcomes. [4] Recognizing this need, the World Health Assembly Resolution 72.16 called for increased efforts to strengthen the provision of emergency care, including training. [5] Improving patient outcomes for emergency medical conditions requires several conditions to be met including: patient awareness of an emergency medical condition, ability to seek emergency medical care, access to a medical facility capable of providing emergency care, and high-quality care in the emergency unit. [6,7] Patients in LMICs face barriers within each of these conditions. Emergency service utilization rates are extremely low in low-income countries (8 per 1,000 population) when compared to high-income countries (264 per 1,000 population).
[8] In one review, 192 emergency facilities were identi ed in 59 LMICs; in the United States alone there are roughly 5,000 emergency facilities. [9] Utilization and access to a health facility does not guarantee access to quality emergency care. Within emergency units in LMICs, mortality is extremely high: 1.8% for adults and 4.8% for paediatrics, as compared to 0.04% in the United States. [9] Quality of care can be poor due to a lack of resources and variability in provider training.
The sick and injured do not present to the emergency unit with a diagnosis and in many settings, children, adults, and pregnant patients all present to the same front-line providers with a chief complaint that may result from traumatic, medical, infectious, and non-communicable causes, or combinations of these.
These chief complaints ultimately represent a broad set of diagnoses, benign to life-threatening, which may span a number of specialties. The front-line provider must be prepared to care for all of these emergency patients, particularly in a resource-limited setting that may be hours or days removed from advanced or specialized care. [10] In order to strengthen emergency care delivery in resource limited settings, the World Health Organization (WHO), in collaboration with the International Committee of the Red Cross (ICRC) and the International Federation for Emergency Medicine (IFEM), developed the Basic Emergency Care (BEC) course in 2015.
[11] The BEC course is a ve-day intensive training course covering core emergency care content, including didactics, practical skills, and small groups. Participants are taught a systematic (ABCDE) approach to use for every patient encounter and review signs and symptoms and management of lifethreatening conditions during the chief complaint-based modules; Shock, Trauma, Di culty in Breathing, and Altered Mental Status. Content is delivered via didactics and small group exercises. A signi cant portion of the course is dedicated to practical skills stations, such as bag-valve mask, bleeding control, and log rolling patients. Skills training re-emphasizes the systematic ABCDE approach. The course is designed to be taught by local providers who have previously taken the course and attended an additional two-day train-the-trainer course after completing the BEC. Here, we describe an early implementation of the BEC Course in two East African countries using a train-the-trainer model.

Methods
The BEC course was implemented in two hospitals in Tanzania and two hospitals in Uganda over one month in 2017. The implementation was performed with the support of the African Federation for Emergency Medicine (AFEM), which has a long history of collaboration with the national emergency medicine societies and Ministries of Health in both Tanzania and Uganda. Both countries have strong national emergency care leads who identi ed participating hospital sites based on their high volume of emergency visits, location on major roads, and support of hospital leadership. All sites provide emergency care services, and at all sites these services are delivered in a less formal manner than the standard emergency unit staffed by non-rotating personnel who have received specialised training in trauma and acute care found in high-income countries.
The Ugandan healthcare delivery system is composed of seven levels -health centres level I-IV; district hospitals; regional referral hospitals, and tertiary referral hospitals. The two participating hospitals in Uganda were Kawolo District Hospital and Mubende Regional Referral Hospital. Kawolo is located 40 km from Kampala in Buikwe district and serves approximately 1.2 million people. It frequently receives casualties from road tra c accidents on the busy Kampala-Jinja Highway. Mubende is located 170 kilometres west of Kampala in Central Uganda. It is a public hospital, funded by the Uganda Ministry of Health and general care provided by the hospital is free. It is the referral hospital for the districts of Mubende, Mityana, Kiboga, and parts of Mpigi District.
The Tanzanian public health system functions in a pyramidal structure composed of six main levels, with the vast majority of health care interactions occurring in the lower tiers: village health posts; dispensaries; health centres; district hospitals; regional hospitals, and referral hospitals. The two participating hospitals in Tanzania were Kisarawe District Hospital and Bagamoyo District Hospital. Kisarwe Hospital is located in the town of Kisarawe, in the Coastal region, about 42 km southwest from Dar es Salaam city. Bagamoyo Hospital is located in the Coastal region in Bagamoyo town, about 65 km northwest from Dar es Salaam city.
The delivery of the intervention in each country followed the same two-step implementation. First, local providers who participated in a BEC pilot course the previous year were brought to the capitol city for the Training-of-Trainers (ToT) course. During this two-day ToT course, these local providers were trained to teach the ve-day BEC course. After successful completion of the ToT course, they quali ed to become trainers of the BEC course and then delivered the ve-day BEC training to front-line provides who participate in the delivery of acute and emergency medical care. Both phases of the intervention in both countries-the two ToT courses in the capital city and the four BEC courses at each hospital-were supported in person by a representative of the national emergency medicine society, physicians who participated in the development of the BEC course, and support personnel from AFEM.
The ToT course consisted of background information about the BEC course, training sessions with peer feedback on giving a lecture, how to teach skills and a session on course logistics.
BEC course participants were required to attend all sessions, and attendance was taken. The schedule of the course is shown in Fig. 1. In all, the course involves 8 core lectures, 6 small group sessions, and 6 skills stations. A multi-method approach was used to evaluate implementation including an assessment, con dence ratings and feedback surveys. Each participant completed a 25-question multiple choice assessment that was developed during BEC pilot testing and covered core concepts in BEC. Differences in pre-and post-test scores were evaluated for each site with a paired t-test. Each participant also completed a con dence reporting questionnaire before and after training. Participants rated their con dence to complete 12 emergency care actions on a scale of 1 (least con dent) to 5 (most con dent).
Differences in pre-and post-con dence scores across all sites were evaluated with a paired t-test by question. Participants completed structured feedback forms after each BEC module and each block of skills training. Post-course qualitative data was collected as free text and analysed for themes.
This project was considered exempt by the Partners Human Research Committee, and was approved by the Uganda Ministry of Health and the Tanzania President's O ce.
[ Figure 1: Basic Emergency Care Course Schedule -uploaded separately at PDF]

Results
Training-of-Trainers Participants A total of 10 participants completed the ToT courses. There were three participants from Tanzania, all participants had previously taken the WHO BEC course and worked in the emergency unit at Muhimbili National Teaching Hospital in Dar es Salaam, two as nurses and one doctor. In Uganda seven participants were trained who also had taken the BEC pilot course.

BEC Course Participants
A total of 59 participants completed the BEC courses. 46% of participants were nurses, 32% doctors, and 22% other cadres (Fig. 2). Overall course attendance, taken daily, was 97%. Con dence Rating Con dence in emergency care skills also improved signi cantly at all sites with an average improvement of 0.74 and ranging from a 0.39-1.05 absolute increase on a 4-point scale (Fig. 3). The largest improvements were seen at Kawolo and Bagamoyo. Improvement was observed across all topics, with the strongest being in the evaluation of a patient with altered mental status and in skills to manage an obstructed airway. This improvement achieved statistical signi cance for all but two questions (emergency management of the injured adult and skills to immobilise patients). The change in con dence score by question across all sites is shown in Fig. 4. What they would change: The most frequent suggestion for improvement was increased time for the course (21.5%, 11/51) while many others stated that they would not change anything about the course (13.7%, 7/51). Other suggestions for course changes included training more people, sessions on ectopic pregnancy and other obstetric topics, and more skills sessions. Comments included: "The time has to at least go for more than these days because participants need more practice of skills before taking up the duties on the patients" -Nursing O cer, Mubende, Uganda "Increase course duration -BEC should be conducted several times" -Nurse, Kisarawe, Tanzania Who they would recommend the course to: Most participants felt that this training should be provided to all health providers including nurses and doctors. Many also stated that police o cers should also receive this training (17.6% 9/51). Others stated that all support staff such as security, cleaners, and administrators should take this course.

Discussion
This was the rst full implementation of the WHO-ICRC-IFEM Basic Emergency Care course, at four hospitals in East Africa, taught by local healthcare providers who completed a ToT course. All sites showed signi cant improvement in both participant emergency care knowledge and con dence in performing emergency care skills after completing the course. The course was well received by participants and supported by hospital administration. Main qualitative feedback themes were: positive reception of the sessions, especially hands-on skills; request for additional BEC trainings; request for obstetric topics; need for more allotted training time.
Strengths of this study include the recruitment of local healthcare providers to train front-line emergency care providers at the implementation sites. Attendance was near perfect for all courses and only two posttests were not completed, allowing for valid analysis of data. By not requiring increased sta ng or resources, implementation costs are kept very low and can be lowered with scale of the ToT program, eliminating international faculty expenses. Training materials are freely available online without any licensing costs. Course skills were taught with locally used equipment, often on loan from the facility hosting the training. Ideally, training occurs at the host facility in donated space. Weaknesses include the lack of patient outcomes and long-term follow up of knowledge and skill retention. Availability of data and materials: All data generated or analysed during this study are included in this published article.

Figure 1
Basic Emergency Care Course Schedule