Designing, Implementing, and Managing a National Emergency Medical Service in Sierra Leone

Abstract

Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.

Improving Access to Healthcare in Sierra Leone: The Role of the Newly Developed National Emergency Medical Service

“…The NEMS ambulance referral system has been designed as a tiered system of care, comprising peripheral health units (PHUs), in charge of the primary assessment and care of patients, a fleet of 81 ambulance units, and healthcare facilities at different levels [14]. It recognizes two main categories of interventions: "red" codes, which are clinically defined as "immediately life threatening", and "yellow" codes, which are clinically defined as "not life threatening but still serious."…”

“…At the time of this research, NEMS activation was initiated by a registered nurse, midwife, or healthcare worker at the PHU level, and all referred cases were appropriately evaluated and managed by trained nurses allocated to the NEMS OC through codes and scripted questions adapted from the Medical Priority Dispatch system [15], available on request from the authors. Triage accuracy and adherence to protocols were overseen by the OC Supervisor [14], and a posthoc cross-check was performed in the category of pregnant women to confirm that the severity of the diagnosis reported coincided with the triage category assigned. Ambulances were staffed by a paramedic and an ambulance care driver, trained in the basic principles of prehospital emergency care, including management of medical emergencies, trauma, obstetrics and gynecologic and pediatric emergencies [14].…”

“…Triage accuracy and adherence to protocols were overseen by the OC Supervisor [14], and a posthoc cross-check was performed in the category of pregnant women to confirm that the severity of the diagnosis reported coincided with the triage category assigned. Ambulances were staffed by a paramedic and an ambulance care driver, trained in the basic principles of prehospital emergency care, including management of medical emergencies, trauma, obstetrics and gynecologic and pediatric emergencies [14]. Treatments performed in the ambulances included oxygen delivery, continuation of fluid administration after peripheral intravenous cannulation performed by nurses at the PHU level, assistance during labor and delivery, administration of rectal misoprostol for the prevention of postpartum hemorrhage, and basic life support and resuscitation maneuvers without the support of automated external defibrillator.…”

“…After initial notification of the incoming referral via telephone call from the sending PHU, patients were identified upon arrival by referral coordinators, and information regarding patient demographics, clinical condition, mode, and time of transport to the referral facility were collected through a paper report form, which was then transcribed into an Epi Info™ datasheet (Centers for Disease Control and Prevention, Atlanta, GA, USA). Data entry Ambulances were staffed by a paramedic and an ambulance care driver, trained in the basic principles of prehospital emergency care, including management of medical emergencies, trauma, obstetrics and gynecologic and pediatric emergencies [14]. Treatments performed in the ambulances included oxygen delivery, continuation of fluid administration after peripheral intravenous cannulation performed by nurses at the PHU level, assistance during labor and delivery, administration of rectal misoprostol for the prevention of postpartum hemorrhage, and basic life support and resuscitation maneuvers without the support of automated external defibrillator.…”

“…In line with recommendations issued by the World Health Organization (WHO), in 2013, the African Federation of Emergency Medicine advocated for the development of prehospital care systems to reduce the high morbidity and mortality rates reported in African countries [ 11 , 12 ]. Thus, in keeping with both WHO guidelines and national health security policies, in 2016, a government-backed joint venture comprising Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Italy), the Research Center in Emergency and Disaster Medicine (CRIMEDIM, Università del Piemonte Orientale, Italy), and the Sierra Leone Ministry of Health and Sanitation (MOHS), designed the first National Emergency Medical Service (NEMS) in Sierra Leone, one of the very few coordinated, structured, and fully equipped prehospital emergency medical services (EMS) in the African continent [ 5 , 13 , 14 ]. The goal of this newly developed entity is to provide a free-of-charge prehospital service coordinated by a centralized operation center (OC), using part of the ambulances donated to the country during the Ebola outbreak [ 14 ].…”