Implementation of a Package of Emergency Care Interventions and Clinical Outcomes.

Abstract

Investments in emergency care systems are vital to ensuring universal health coverage and improving health outcomes in low- and middle-income countries. To assess whether a package of emergency care interventions is associated with improved patient mortality and clinical care quality. This pre-post quality improvement study was conducted at a single urban referral hospital emergency unit (EU) in Monrovia, Liberia, to assess clinical and educational outcomes resulting from the implementation of a package of interventions from January 1, 2018, through June 30, 2019. Final analysis was performed in November 2023. Data from a random subset of adult patient encounters were collected retrospectively for the 12 months and compared with all adult patient presentations to the EU during the 6-month program implementation. Triage, standardized documentations, and clinical teaching via a formal curriculum and bedside clinical mentorship. The primary outcome was all-cause mortality within 24 hours. Secondary outcomes included mortality at 48 hours, in-EU mortality, and EU quality process indicators. Multivariable logistic regression models were constructed to compare the association between program implementation and all-cause mortality. A total of 344 preimplementation patients were compared with 1073 patients enrolled during the program with largely similar baseline characteristics between the 2 groups (mean [SD] age, 41.4 [16.4] vs 40.1 [17.3] years: 178 [51.7%] male and 164 [47.7%] female vs 601 [56.0%] male and 472 [44.0%] female; and 163 [47.3%] vs 510 [47.5%] near a hospital). All-cause mortality at 24 and 48 hours was significantly different between the preimplementation and implementation periods (27 [8.3%] vs 40 [3.9%], P < .001, and 34 [10.4%] vs 52 [5.0%], P < .001, respectively). In-EU mortality was significantly different between the 2 groups (13.5% [44 of 327] vs 7.1% [73 of 1031], P < .001). In multivariable regression, the adjusted odds of death at both 24 and 48 hours among patients in the intervention period was half that of the preintervention period. This quality improvement study provides evidence that a set of interventions is associated with improved emergency care quality and reduced mortality. The high rates of EU-based mortality suggest the critical need to include EC in all facility-based quality improvement efforts.