BackgroundEmergency care (EC) can improve health outcomes and reduce disparities [1]. Despite this, EC is often extremely limited in low-and middle-income countries (LMICs), including Haiti [2,3]. In addition to investments in education, human resources and operations, developing successful emergency care systems requires designing, building and maintaining high-quality emergency departments (EDs).Studies from high-income settings have demonstrated that an ED's physical infrastructure is closely related to its operational success [4][5][6]. However, no standards exist for ED design in LMICs. Uniform application of design principles from high-income settings would be inappropriate due to variations in disease burden, staff training, health system characteristics, and financing. To address this gap, we present our experience with ED design at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti.As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify priority design features Marsh RH, et al. Emergency Department Design in Low-and Middle-Income Settings:

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BackgroundIn Haiti, like many low-income countries, traumatic injuries are leading causes of morbidity and mortality. Yet, little is known about the epidemiology of traumatic injuries in Haitian EDs. Improved understanding of injury patterns is necessary to strengthen emergency services and improve emergency provider education.MethodsThis was a retrospective cohort study of trauma patients at an academic hospital in central Haiti over 6 months. Visits were identified from the electronic medical record, and paper charts were manually reviewed. Data, including demographics, timing of presentation, injuries sustained, treatments received and ED disposition were extracted using a standardised form and later analysed in SAS V.9.3.ResultsOf 1401 patients, 66% were male, and the average age was 26.8 years. Most visits were due to road traffic injuries (RTIs; 48%) followed by falls (22%). Trauma mechanism varied significantly by age (p<0.001): falls predominated in children under 5 years (56%) versus RTIs for adults (59%). Only 14% of patients injured on motorcycles used helmets and 30% of those injured in motor vehicles used seatbelts. Only 18% of patients arrived within 1 hour of the trauma. Skin or soft tissue injuries were the most common (58%), followed by extremity or pelvic fractures or dislocations (23%). Most patients (81%) were discharged, 14% were admitted or stayed over 24 hours in the ED and 0.8% died in the ED. Of the admitted patients, 61% had surgery, 79% of which were orthopaedic. Patients using helmets or seatbelts were more likely to be discharged than those not using protective equipment (p=0.008).ConclusionsIn this trauma population, RTIs and falls were the most common trauma mechanisms, safety feature use was rare, and most injuries were musculoskeletal. Presentation was delayed and mortality was low, but many patients required surgery. These findings have significant clinical, public health, operational and training implications.

Introduction In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. Methods We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. Results Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). Conclusion Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

Program/Project Purpose: Globally, including in resource-limited settings, a significant proportion of the global burden of disease could be addressed by quality emergency care. Despite this, emergency medicine (EM) specialists are rarely available in low and middle-income countries. In Haiti, there are no current EM residency training programs. The newly established EM residency at Hôpital Universitaire de Mirebalais (HUM) aims to train emergency medicine specialists in Haiti to address this gap. Structure/Method/Design: The residency program was developed and is run in conjunction with the Haitian National Medical School, Ministry of Health, HUM, and the non-governmental organizations Zamni Lasante/Partners In Health. The program is a three-year residency in EM, with a curriculum adapted from that of the Accreditation Council for Graduate Medical Education (ACGME) and the African Federation of Emergency Medicine. The permanent program faculty consists of three US-trained board certified EM physicians (a program director and two departmental co-chairs), and two Haitian family physicians with emergency medicine work experience and a six-month certificate in EM. Given the limited incountry capacity, EM physicians from the United States and Canada volunteer as visiting professors and provide bedside teaching, clinical supervision, and didactic lectures. Over time, as the Haitian EM community is developed, the residency will transition to an entirely Haitian run program.Outcomes & Evaluation: The first class of EM residents began in October 2014. Residents were selected through a written examination and scored interviews. Throughout the program, resident performance will be evaluated with faculty evaluations and written annual examinations. Logbooks will be used to verify that residents meet the required number of procedures, ultrasounds, and supervised cases. Residents must pass an end of residency competency examination. Lastly, residents, permanent and visiting EM faculty, and Haitian medical education leadership will evaluate the residency program as a whole. This includes an evaluation of the residency model, which relies on a combination of transient and permanent faculty. Going Forward: There are a number of challenges to the first EM residency in Haiti, including local leadership, curriculum adaptation, and sustainability. Currently, the program relies heavily on visiting EM faculty. We anticipate the new Haitian residents and faculty will assume program leadership over the next 3 years, with support from permanent and visiting EM faculty. Additionally, existing EM curricula are being adapted to fit the Haitian context and burden of disease. Lastly, the program will require full integration into the Haitian medical education system, permanent funding, and further professionalization of the specialty to ensure its sustainability. The program structure is designed to be adaptable yet robust to meet these challenges.Funding: Funding for the residency is included within the operational budget of HUM, which is su...