POSICIONAMIENTO TEÓRICO PERSONAL 1 Modelo Socio crítico

There is a policy designed to ensure that every acute care facility in the country has an area designated for emergency care. At district hospitals, this area is typically present, though not necessarily staffed by a provider trained in emergency care or a provider that is assigned solely to the emergency unit. Further, patients are often not triaged, and are generally seen in order of arrival. At teaching hospitals, emergency units are typically staffed 24 hours per day, usually by a provider trained in emergency care who is assigned to the emergency unit; teaching hospitals have standardised triage protocols, and are seen in order of acuity. It is estimated that less than 25% of the population has 24-hour access to facility-based emergency care in a dedicated unit with independent, non-rotating, trained emergency care providers regardless of urban or rural residence.

Facility-based assessments of emergency care capacity have demonstrated marked deficiencies, even for low-cost resources (e.g., basic airway supplies, chest tubes, plaster of Paris, essential medications).6,8,16 _{While resource} deficiencies are more commonly encountered at district hospitals, care at larger hospitals (i.e., regional and teaching hospitals) is also limited by a lack of essential resources.24

Despite a policy mandating triage of acutely ill and injured patients prior to registration, triage for emergency conditions is rarely performed outside of teaching and some regional hospitals. Specifically, district hospitals typically lack formal triage protocols and personnel dedicated to triage at all times. In facilities that perform triage routinely, there is a lack of time targets for certain triage destinations (i.e., acuity levels) and no compliance tracking for triage time targets.

There are two accredited emergency medicine specialist training programmes in Ghana, in addition to specialist training programmes in anaesthesia and critical care. Although there are orthopaedic specialist training programmes, these do not teach the breadth of general trauma surgery, which includes resuscitation and surgical care of injuries to the neck, chest, pelvis and abdomen. Thus, there is no comprehensive training

program for trauma surgery. Recently, the Nursing and Midwifery Council of Ghana has accredited post-graduate degree courses for emergency nursing.

Providers who regularly care for emergency conditions are supposed to have undergone dedicated training in emergency care according to a GHS policy; however, non-doctors rarely receive dedicated emergency care training. When emergency care training is provided to doctors, it typically only entails care for injuries and does not cover the care of other emergency conditions.

Screening at the time of registration in the emergency unit is under-utilised countrywide. Some facilities screen each patient for diabetes, HIV and/or TB. However, outside of times of outbreak, most patients do not get screened for other conditions of public health importance, such as domestic violence and child maltreatment, other forms of violence, or substance abuse. As demonstrated during the recent Ebola epidemic, there is a mechanism for screening patients at time of registration at an emergency unit for highly contagious conditions (e.g., Ebola, SARS, MERS) with links to public health officials for case definitions and reporting.

Some emergency units use protocols to govern the management of key emergency conditions, but these are not consistently used and are often not externally validated, particularly those outside of emergency obstetric care. It is estimated that less than 25% of the population have access to essential surgical care in a staffed operating theatre within two hours of acute surgical illness or injury. Similarly, due to prohibitively expensive user-fees, lack of resources and a shortage of trained providers, orthopaedic and specialist surgical care services (e.g., neurosurgery, advanced burn care) are not available for the majority of the population when needed.

There are no nationally agreed upon targets for emergency unit length of stay. Although there is a policy regarding the information that ought to be communicated to patients about their disposition or discharge, there are no protocols to guide this interaction. Further, for patients who are discharged, there are rarely formal linkages between the emergency unit and primary/longitudinal care or other outpatient services.

ACTION PRIORITIES

Establish facility designation criteria and an accreditation system for specific emergency and trauma care services.

Implement team-based and inter-professional training for emergency care to improve care delivery and strengthen communication skills and relationships among nurses and doctors; ideally, this would begin at the pre-service level (i.e., during training).

Adapt externally validated protocols for the care of emergency conditions to local contexts, and implement the protocols at hospitals countrywide; compliance with protocols should be linked to facility designation and accreditation schemes.

Review, with stakeholders (e.g., Ghana College of Physicians and Surgeons, relevant universities), the existing curriculae for orthopaedic surgery and general surgery training programmes in Ghana and trauma surgery programmes in other countries to identify gaps related to the care of the injured; work with stakeholders to redress the gaps and update the curriculae of surgical training programmes to ensure that injured patients in need of trauma surgical care can receive it when needed.

• Establish routine screening for sentinel conditions prior to registration at all acute care facilities with links to public health officials for case definitions and reporting.

• Train district hospital providers in triage components to promote patients being seen in order of acuity.