Article Text
Abstract
Objectives Emergency departments (ED) are the basic unit of international emergency medicine, but often differ in fundamental features. This study sought to describe and characterise ED in the capital city of Nigeria, Abuja.
Methods All ED open 24 h/day 7 days/week to the general public were surveyed using the national ED inventories survey instrument (http://www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to calendar year 2008.
Results Twenty-four ED participated (83% response). All were located in hospitals, which ranged in size from six to 250 beds. The majority (92% CI 73% to 100%) had a contiguous layout with medical and surgical care provided in one area. All ED saw both adults and children, with a median of 1500 annual visits (IQR 648–2328). Almost half of respondents (46%; CI 26% to 67%) thought their ED operated under capacity, none thought that their ED was over capacity. Only 4% of ED surveyed had dedicated CT scanners, 25% had cardiac monitoring and none had negative-pressure rooms. There was wide variation in the types of emergencies that were identified as being treatable 24 h/day 7 days/week; these appeared to correlate with ED consultant availability.
Conclusions Although ED location and layout in Abuja do not differ greatly from that in a typical US city, ED utilisation was lower and fewer resources and capabilities were available. The lack of technological and human resources raise questions about what critical technologies are needed in resource-limited settings, and whether Nigeria should consider training emergency medicine physicians to meet its workforce needs.
- Anaphylaxis allergy
- asthma
- clinical
- emergency care systems
- emergency department
- emergency department classification
- epidemiology
- international emergency medicine
- Nigeria
- research
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- Anaphylaxis allergy
- asthma
- clinical
- emergency care systems
- emergency department
- emergency department classification
- epidemiology
- international emergency medicine
- Nigeria
- research
In the past decade, there has been growing interesting in the development of emergency medicine around the world, including in sub-Saharan Africa.1 ,2 While studies have focused on overall emergency medicine infrastructure, little has been written to describe existing emergency departments (ED) internationally.3 Examination of ED in diverse settings could provide additional insight into how to improve emergency care.
With a population of approximately 150 million, Nigeria is the most populous country in Africa. Ranking 37th worldwide in terms of gross domestic product, Nigeria's economy is one of the fastest growing in the world.4 Unfortunately, Nigeria's healthcare development has not kept up with the country's rapid economic growth. Life expectancy still hovers at 45 years. The mortality rate for children younger than 5 years is more than double the global average. The United Nations' human development index ranks Nigeria 154th out of 179 countries.5
Nigeria has a universal healthcare structure that supports the provision of primary, secondary and tertiary levels of health services, which are funded by the local, state and federal governments, respectively.6 The level of overall government contribution to healthcare is low, with health expenditures constituting 5% of gross domestic product, while out-of-pocket payments contribute 65% to the payment mix.4 The ‘brain drain’ has significantly impacted the country: an estimated 55 000 physicians practice in Nigeria, approximately the same number of Nigerian doctors who have emigrated to the USA.7
Emergency medicine does not exist as a speciality in Nigeria. There is no postgraduate emergency medicine training programme available in the country; those who wish to train in emergency medicine apply to the few coveted spots at a registrarship in South Africa that accepts foreign African doctors.2 However, information provided by the Nigerian Ministry of Health and supported by anecdotal reports from doctors practising in Nigeria suggest that there are ED in Nigeria, and that Abuja, as its capital, is at the forefront of ED development.
No study has sought to understand how emergency medicine is delivered in Nigeria, particularly at the level of the ED—the basic unit of emergency medicine. We aimed to understand the current state of ED in Abuja, Nigeria.
Methods
This was a cross-sectional descriptive study with web-based surveys administered to the physician administrator at each Abuja ED. Sites without internet access were invited to participate in a paper survey. Consistent with terminology used in NEDI USA, an ED was defined as an emergency care facility that is open 24 h/day, 7 days/week. A list of ED was obtained from the Ministry of Health and verified for completeness by two local physicians. All eligible ED were contacted and surveyed. The study was coordinated by the Emergency Medicine Network (EMNet) (http://www.emnet-nedi.org). This study was determined to be exempt by the institutional review board.
A 23-item questionnaire was employed. Participants were specifically asked about ED characteristics with reference to calendar year 2008. Survey questions were partly drawn from a survey that has been administered in hundreds of US ED.8 Questions were subdivided into four categories: ED characteristics; patient experiences in the ED; capacity; and resources and capabilities. Before implementation, survey questions were reviewed by members of the EMNet steering committee and several country coordinators. The survey was previously used in four other countries to profile their ED9 (see supplementary appendix 1, available online only).
Responses were directly downloaded from the EMNet website and then recorded onto an Excel spreadsheet. Responses received were maintained on a secure, password-protected server. Descriptive statistics were calculated using Stata V.11.0.
Results
General characteristics
Out of 29 ED in Abuja, 24 participated in the survey (83%). All were located in hospitals; these hospitals ranged in size from six to 250 beds. Most (75%) were independent departments; the rest belonged to medicine or surgery departments. The majority (92%) had a contiguous layout (with medical and surgical care provided in one area); most used triage to service (eg, triage of patients to a specific emergency service, eg, medical vs surgical team). All ED saw both adults and children, and had a median annual visit volume of 1500 visits (figure 1). Respondent and non-respondent ED (n=5) did not differ with respect to ownership, metropolitan status, or academic status.
Patient experiences in the ED
Most (75%) respondents answered that less than 20% of their patient population arrived by ambulance. Patient length of stay varied, with 38% of ED reporting that patients typically stayed less than 1 h and 25% reporting over 6 h. In almost half of the ED (40%), more than 40% of ED visits led to admission; 20% reported a greater than 80% admission rate (table 1).
Capacity
None of the respondents thought that their ED was over capacity. Almost half of respondents (46%; 95% CI 26% to 67%) thought their ED operated under capacity.
Resources and capabilities
Although every ED in the survey met the criteria of being open 24 h/day 7 days/week, to the general public, most ED were not staffed round the clock by doctors. Indeed, doctors were physically present round the clock in only 21% (95% CI 3% to 38%) of ED. However, in the 19 ED without round-the-clock ED physician staffing, doctors were available from within the hospital in 67% (95% CI 46% to 87%) of the hospitals, meaning that only 13% (95% CI 0% to 27%) of all ED lacked round-the-clock physician availability. For the remaining three, there was at least one nurse on duty in the ED 24 h/day 7 days/week.
Technological support was lacking in the majority of surveyed ED. For example, a dedicated CT scanner for the ED was available in only 4% of the ED. None of the ED sampled had negative-pressure rooms. The only exception to this general lack of resources was the availability of a round-the-clock clinical laboratory, which was available in 83% of ED (table 1).
Emergency types that could be treated 24 h/day 7 days/week in sampled ED range from low (dental was treatable in 4% (95% CI 0% to 13%) of ED) to high (trauma was treatable in 96% (95% CI 87% to 100%) and general medical emergencies in 100% (95% CI 86% to 100%)) (see supplementary table 2, available online only). Consultant availability to ED also varied considerably depending on the speciality type. The availability of consultants appeared to correlate with the type of emergency that the ED were capable of treating (see supplementary figure 2, available online only).
Discussion
On the surface, ED in Abuja, Nigeria, appear to resemble many ED in the USA, as previously described.8 The large majority have a contiguous layout with medical and surgical emergencies seen in one area. Most are independent departments in their own right, while others function under the auspices of the departments of medicine or surgery.
However, Abuja ED differ significantly from US ED in several major ways. First, visit volumes are very low for the individual ED. This is consistent with the finding that almost half of the respondents characterise their ED as under capacity and none as over capacity. Moreover, it is not only the individual ED that have low visit volumes: a rough calculation based on the median of 1500 visits per hospital yields 54 ED visits per 1000 population. The same metric in the USA is 415, an almost eightfold difference in utilisation.4 This measure is similarly many fold less than in other developed countries such as the UK and Australia.4
Why is there such a low visit volume to Abuja ED? One possibility is that patients go to other types of facilities to get emergency care. Our study examined only ED, defined as facilities with 24 h/day 7 days/week access to the general public, and did not include the many other types of facilities that are capable of providing at least some emergency care (eg, primary care and urgent care clinics). Patients may choose only to come to the ED if they have a severe, life-threatening illness; this could explain why there is such a high rate of admission. Yet another possibility is that patients do not come to the ED (or any health facility) because they lack the ability to pay for these services. A study of emergency medicine in Rwanda found payment to be a major hindrance to emergency care.1 It was not the explicit aim of this study to identify barriers to access to overall healthcare, but this is an area that deserves further study to investigate whether people who do not come to ED are able to get adequate care elsewhere or forego it altogether.
Second, in the majority of Abuja ED, there is no doctor available round the clock, though in most of the cases, there is a doctor available somewhere in the hospital. The lack of round-the-clock physician staffing of the ED could be a result of the brain drain and/or reflective of low visit volumes. This distinction should be explored in further studies: while achieving physician staffing of ED 24 h/day 7 days/week may be an ideal goal for developed countries with a well-formed emergency medicine infrastructure, this may not be a realistic—or even desired—goal for developing countries with low ED visit volumes.
Third, perhaps a more pressing concern is the lack of resources in Abuja ED. That there is no dedicated CT scanner except in 4% of ED may seem an anathema to those used to resource-rich settings, but this pales in comparison to the problem of not having cardiac monitors in 75% of ED. Almost every ED reported treating trauma patients, but only 38% had ventilators. Tuberculosis is rampant in Nigeria, but none of the ED had negative-pressure rooms. Having no neurosurgeon or CT scanner is a problem that may be resolved through transfer to another ED capable of delivering higher-level speciality care, but even the basic ED should have core technologies such as cardiac monitoring. Further study to identify a ‘checklist’ of such key technologies could be useful for developing countries to assess how best to leverage limited resources.
Fourth, the Abuja ED self-reported that they could not treat many types of emergencies. While general medical and surgical issues could be handled by almost every ED, the numbers quickly fell when it came to other emergencies, such as toxicological and cardiology emergencies. The types of emergencies that ED identified they were capable of treating appeared to correlate directly with the availability of specialist consultants: when the consultant is available, the ED can treat the emergency; if not, then they could not. However, the types of emergencies surveyed are all within the scope of practice of trained emergency medicine practitioners.10 In resource-poor settings with a dearth of doctors (and in particular, specialists), this may provide additional impetus to train emergency medicine physicians who have a core set of skills to address initial stabilisation of all common emergencies.1
Limitations
We recognise that this is an initial study with descriptive statistics, but it provides new information to guide efforts to advance emergency care in Nigeria and other developing countries. To our knowledge, a validated instrument to assess ED worldwide does not exist. Questions from our survey have been used in US studies,8 and have furthermore been used in several other countries,9 ensuring usability and that the wording of questions was appropriate for diverse contexts.
Another potential limitation is that this study relies on self-reported data. While exact figures would be ideal, the surveyed hospitals lack such record keeping, and the closest approximation is self-reports from ED physician administrators.
Finally, the response rate in the study was 83%, with five ED choosing not to participate in the study. If their experiences or responses differed markedly from those studied, this could introduce bias. The five missing sites did not, however, differ in key parameters from the more than 80% who did participate.
Conclusion
While ED in the Nigerian capital city, Abuja, resemble US ED in general, there are several major differences that raise questions including where (and whether) patients get emergency care, what types of technological resources are necessary in resource-limited settings, and whether, in areas suffering from a ‘brain drain’, it might be more efficient to train emergency medicine physicians preferentially to meet the country's workforce needs. We hope that this initial study and other studies that follow will help to improve emergency care in Nigeria and other developing countries.
Acknowledgments
The authors would like to acknowledge the dedicated individuals who are the pioneers of emergency medicine in Africa and other developing settings. They wish to thank Janice Espinola for her statistical assistance, and all of the respondents for their time in completing the surveys.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Download Supplementary Data (PDF) - Manuscript file of format pdf
- Download Supplementary Data (PDF) - Manuscript file of format pdf
- Download Supplementary Data (PDF) - Manuscript file of format pdf
- Download Supplementary Data (PDF) - Manuscript file of format pdf
- Download Supplementary Data (PDF) - Manuscript file of format pdf
Footnotes
Additional materials are published online only. To view these files please visit the journal online (http://dx.doi.org/10.1136/emermed-2011-200695).
Competing interests None.
Ethics approval Ethics approval was provided by Partners Healthcare.
Provenance and peer review Not commissioned; internally peer reviewed.
Data sharing statement Because survey respondents were assured at the outset that their responses would be available to the public only in aggregate form, the authors are not able to freely share the data obtained.
Linked Articles
- Primary survey