Abstract
ObjectivesTo assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.DesignRetrospective cohort analysis with multivariable logistic regression.SettingSingle rural Ugandan emergency unit.ParticipantsAll patients presenting for care from 2009 to 2019.InterventionsThree cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: ‘Direct Supervision’ (2009–2010) emergency medicine physicians directly supervised all care; ‘Indirect Supervision’ (2010–2015) emergency medicine physicians were consulted as needed; ‘Independent Care’ (2015–2019) no emergency medicine physician supervision.Primary outcome measureThree-day mortality.Results38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts (‘Direct’ 3.8%, ‘Indirect’ 3.3%, ‘Independent’ 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals (‘Direct’ 32%, ‘Indirect’ 19%, ‘Independent’ 13%, p<0.001). After controlling for vital sign abnormalities, ‘Direct’ and ‘Indirect’ supervision were both significantly associated with reduced OR for mortality (‘Direct’: 0.57 (0.37 to 0.90), ‘Indirect’: 0.71 (0.55 to 0.92)) when compared with ‘Independent Care’. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals (‘Direct’: 0.44 (0.22 to 0.85), ‘Indirect’: 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals (‘Direct’: 0.81 (0.44 to 1.49), ‘Indirect’: 0.82 (0.58 to 1.16)).ConclusionsEmergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.
Reference53 articles.
1. World Health Assembly 72 . Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured. Geneva: World Health Organization, 2019. https://apps.who.int/iris/handle/10665/329363
2. World Health Assembly 60 . Health systems: emergency-care systems. Geneva: World Health Organization, 2007. https://apps.who.int/iris/handle/10665/22596
3. Towards a regional strategy for resolving the human resources for health challenges in Africa
4. World Health Organization . Working together for health : the world health report 2006 : overview. Travailler ensemble pour la santé : rapport sur la santé dans le monde 2006 : résumé, 2006. Available: https://apps.who.int/iris/handle/10665/69256
5. Emergency care in sub-Saharan Africa: results of a consensus conference;Calvello;Afric J Emer Med,2013