Publications by authors named "Regan H Marsh"

34 Publications

Mass Casualty Incident Management for Resource-Limited Settings: Lessons From Central Haiti.

Disaster Med Public Health Prep 2021 Mar 11:1-7. Epub 2021 Mar 11.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings.

Results: Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers.

Conclusion: These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.
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http://dx.doi.org/10.1017/dmp.2020.439DOI Listing
March 2021

Examining Parity among Black and Hispanic Resident Physicians.

J Gen Intern Med 2021 Jun 24;36(6):1722-1725. Epub 2021 Feb 24.

Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA.

Background: The US physician workforce does not represent the racial or ethnic diversity of the population it serves.

Objectives: To assess whether the proportion of US physician trainees of Black race and Hispanic ethnicity has changed over time and then provide a conceptual projection of future trends.

Design: Cross-sectional, retrospective, analysis based on 11 years of publicly available data paired with recent US census population estimates.

Participants: A total of 86,303 (2007-2008) to 103,539 (2017-2018) resident physicians in the 20 largest US Accreditation Council for Graduate Medical Education resident specialties.

Main Measures: Changes in proportion of physician trainees of Black race and Hispanic ethnicity per academic year. Projected number of years it will then take, for specialties with positive changes, to reach proportions of Black race and Hispanic ethnicity comparable to that of the US population.

Key Results: Among the 20 largest specialty training programs, Radiology was the only specialty with a statistically significant increase in the proportion of Black trainees, but it could take Radiology 77 years to reach levels of Black representation comparable to that of the US population. Obstetrics/Gynecology, Emergency Medicine, Internal Medicine/Pediatrics, and Orthopedic Surgery demonstrated a statistically significant increase in the proportion of Hispanic trainees, but it could take these specialties 35, 54, 61, and 93 years respectively to achieve Hispanic representation comparable to that of the US population.

Conclusions: Among US residents in the 20 largest specialties, no specialty represented either the Black or Hispanic populations in proportions comparable to the overall US population. Only a small number of specialties demonstrated statistically significant increases. This conceptual projection suggests that current efforts to promote diversity are insufficient.
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http://dx.doi.org/10.1007/s11606-021-06650-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175607PMC
June 2021

Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities.

Cureus 2021 Feb 16;13(2):e13381. Epub 2021 Feb 16.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient's outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
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http://dx.doi.org/10.7759/cureus.13381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891794PMC
February 2021

Pandemic Care Through Collaboration: Lessons From a COVID-19 Field Hospital.

J Am Med Dir Assoc 2020 11 8;21(11):1563-1567. Epub 2020 Sep 8.

Boston Hope Field Hospital, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA.

During the surge of Coronavirus Disease 2019 (COVID-19) infections in March and April 2020, many skilled-nursing facilities in the Boston area closed to COVID-19 post-acute admissions because of infection control concerns and staffing shortages. Local government and health care leaders collaborated to establish a 1000-bed field hospital for patients with COVID-19, with 500 respite beds for the undomiciled and 500 post-acute care (PAC) beds within 9 days. The PAC hospital provided care for 394 patients over 7 weeks, from April 10 to June 2, 2020. In this report, we describe our implementation strategy, including organization structure, admissions criteria, and clinical services. Partnership with government, military, and local health care organizations was essential for logistical and medical support. In addition, dynamic workflows necessitated clear communication pathways, clinical operations expertise, and highly adaptable staff.
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http://dx.doi.org/10.1016/j.jamda.2020.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832230PMC
November 2020

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

Afr J Emerg Med 2020 Sep 15;10(3):145-151. Epub 2020 Jul 15.

Brown University, Department of Emergency Medicine, Providence, RI, USA.

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.
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http://dx.doi.org/10.1016/j.afjem.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474244PMC
September 2020

The Gender Gap in Surgical Residencies.

JAMA Surg 2020 09;155(9):893-894

Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2020.2171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391174PMC
September 2020

COVID-19 preparedness in Malawi: a national facility-based critical care assessment.

Lancet Glob Health 2020 07 25;8(7):e890-e892. Epub 2020 May 25.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2214-109X(20)30250-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247792PMC
July 2020

Emergency Department Design in Low- and Middle-Income Settings: Lessons from a University Hospital in Haiti.

Ann Glob Health 2020 01 20;86(1). Epub 2020 Jan 20.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, US.

Background: Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs).

Objective: We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations.

Methods: As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed.

Findings And Conclusions: ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the "front end" of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.
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http://dx.doi.org/10.5334/aogh.2568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978988PMC
January 2020

A comprehensive district-level laboratory intervention after the Ebola epidemic in Sierra Leone.

Afr J Lab Med 2019 22;8(1):885. Epub 2019 Oct 22.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States.

Background: The 2014-2016 Ebola outbreak exposed the poor laboratory systems in Sierra Leone. Immense needs were recognised across all areas, from facilities, diagnostic capacity, supplies, trained personnel to quality assurance mechanisms.

Objective: We aimed to describe the first year of a comprehensive intervention, which started in 2015, in a public hospital's general laboratory serving a population of over 500 000 in a rural district.

Methods: The intervention focused on (1) supporting local authorities and healthcare workers in policy implementation and developing procedures to enhance access to services, (2) addressing gaps by investing in infrastructure, supplies, and equipment, (3) development of quality assurance mechanisms via mentorship, bench-side training, and the introduction of quality control and information systems. All work was performed alongside counterparts from the Ministry of Health and Sanitation.

Results: We observed a strong increase in patient visits and inpatient and outpatient testing volumes. Novel techniques and procedures were taken up well by staff, leading to improved and expanded service and safety, laying foundations for further improvements.

Conclusion: This comprehensive approach was successful and the results suggest an increase in trust from patients and healthcare workers.
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http://dx.doi.org/10.4102/ajlm.v8i1.885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852544PMC
October 2019

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

Circ Heart Fail 2019 11 29;12(11):e006214. Epub 2019 Oct 29.

Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183732PMC
November 2019

Care of Pregnant Women: Experience from a Maternity-Specific Ebola Isolation Unit in Sierra Leone.

J Midwifery Womens Health 2019 Jul 26;64(4):493-499. Epub 2019 Jun 26.

Partners In Health, Boston, Massachusetts.

Introduction: The Ebola virus disease epidemic was devastating to the West African region, particularly for pregnant women. Prior to the epidemic, maternal mortality in this region was among the highest in the world. Throughout the region, screening of patients with Ebola was difficult, as the symptoms of malaria or typhoid mimicked Ebola, but even more difficult for pregnant women, because of the large overlap between Ebola symptoms and pregnancy-related complications. In November 2014, the world's first maternity-specific isolation and screening system, to our knowledge, was created at the Princess Christian Maternity Hospital in Freetown to meet the emergent needs of the population of pregnant women during the epidemic.

Process: Starting in December 2014 through June 2016, in collaboration with hospital leadership and the Ministry of Health and Sanitation, Partners In Health supported Princess Christian Maternity Hospital in creating a safer health care environment with the shared goal of improving safety and health outcomes and of addressing the unique needs of pregnant women, by focusing on improving 4 key areas: 1) screening, 2) isolation, 3) laboratory diagnostics, and 4) clinical service delivery in isolation, including human resource management and training.

Outcomes: The screening guidelines were adapted to include maternal health care considerations, a new screening area was constructed, the laboratory result turnaround time was reduced, and the isolation unit was improved to enhance safety and care delivery. Human resources were supported with additional staff hired and trainings on infection prevention and control, overall resulting in better preparing Princess Christian Maternity Hospital to provide care for pregnant women during outbreaks.

Discussion: The authors' experience at Princess Christian Maternity Hospital provides a model of screening, isolation, and care specifically for maternity patients, and directly addresses infection risk and mortality. The recommendations we provide can be used in future outbreaks.
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http://dx.doi.org/10.1111/jmwh.12997DOI Listing
July 2019

Epidemiology of traumatic injuries presenting to an ED in Central Haiti: a retrospective cohort study.

Emerg Med J 2019 Jul 15;36(7):389-394. Epub 2019 Mar 15.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: In 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.

Methods: This 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.

Results: Of 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).

Conclusions: In 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.
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http://dx.doi.org/10.1136/emermed-2018-207559DOI Listing
July 2019

Addressing the immediate need for emergency providers in resource-limited settings: the model of a six-month emergency medicine curriculum in Haiti.

Int J Emerg Med 2018 Apr 6;11(1):22. Epub 2018 Apr 6.

Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.

Background: In many resource-limited settings, emergency medicine (EM) is underdeveloped and formal EM training limited. Residencies and fellowships are an ideal long-term solution but cannot meet immediate needs for emergency providers, while short-term programs are often too limited in content. We describe a third method successfully implemented in Haiti: a medium-duration certificate program to meet the immediate need for emergency specialists.

Methods: In conjunction with the Haitian Ministry of Health and National Medical School, we developed and implemented a novel, 6-month EM certificate program to build human resources for health and emergency care capacity. The program consisted of didactic and supervised clinical components, covering core content in EM. Didactics included lectures, simulations, hands-on skill-sessions, and journal clubs. Supervised clinical time reinforced concepts and taught an EM approach to patient care.

Results: Fourteen physicians from around Haiti successfully completed the program; all improved from their pre-test to post-test. At the end of the program and 9-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily. Participants found clinical supervision and simulation particularly useful. Key components to our program's success included collaboration with the Ministry of Health and National Medical School, supervised clinical time, and the continual presence of a course director. The program could be improved by a more flexible curriculum and by grouping participants by baseline knowledge levels.

Conclusion: Medium-duration certificate programs offer a viable option for addressing immediate human resource gaps in emergency care, and our program offers a model for implementation in resource-limited settings. Similar options should be considered for other emerging specialties in resource-limited settings.
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http://dx.doi.org/10.1186/s12245-018-0182-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889369PMC
April 2018

Facing the Shortage of IV Fluids - A Hospital-Based Oral Rehydration Strategy.

N Engl J Med 2018 Apr 21;378(16):1475-1477. Epub 2018 Mar 21.

From the Department of Emergency Medicine, Brigham and Women's Hospital (A.M.P., R.H.M., E.J.N., C.W.B., S.A.R., S.K.), the Department of Emergency Medicine, Massachusetts General Hospital (A.M.P.), and Partners in Health (R.H.M., S.A.R.) - all in Boston; and the Harvard Humanitarian Initiative, Cambridge (E.J.N., S.K.) - all in Massachusetts.

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http://dx.doi.org/10.1056/NEJMp1801772DOI Listing
April 2018

Gaps in physical access to emergency care in sub-Saharan Africa.

Lancet Glob Health 2018 03 26;6(3):e240-e241. Epub 2018 Jan 26.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2214-109X(18)30026-3DOI Listing
March 2018

Generalized Itching and Lower-Extremity Spasticity in a Patient with Intrathecal Baclofen Pump.

J Emerg Med 2018 Jan 25;54(1):116-120. Epub 2017 Oct 25.

Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jemermed.2017.08.090DOI Listing
January 2018

Global Emergency Medicine: A Review of the Literature From 2016.

Acad Emerg Med 2017 09 11;24(9):1150-1160. Epub 2017 Aug 11.

Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.

Objectives: The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

Methods: This year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles.

Results: A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441.

Conclusions: In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.
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http://dx.doi.org/10.1111/acem.13216DOI Listing
September 2017

Diffuse Abdominal Pain and Fever in an Elderly Man.

J Emerg Med 2017 07 28;53(1):130-134. Epub 2017 Mar 28.

Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jemermed.2016.08.005DOI Listing
July 2017

Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti.

Int Emerg Nurs 2017 Jul 20;33:26-31. Epub 2017 Feb 20.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States; University Teaching Hospital at Mirebalais, Mirebalais, Haiti; Partners In Health, Boston, MA, United States.

Background: Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti.

Methods: A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis.

Results: Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively.

Conclusion: This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.
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http://dx.doi.org/10.1016/j.ienj.2016.12.004DOI Listing
July 2017

Minimally Symptomatic Infection in an Ebola 'Hotspot': A Cross-Sectional Serosurvey.

PLoS Negl Trop Dis 2016 11 15;10(11):e0005087. Epub 2016 Nov 15.

Division of Global Health Equity, Brigham and Women's Hospital, Boston, United States of America.

Introduction: Evidence for minimally symptomatic Ebola virus (EBOV) infection is limited. During the 2013-16 outbreak in West Africa, it was not considered epidemiologically relevant to published models or projections of intervention effects. In order to improve our understanding of the transmission dynamics of EBOV in humans, we investigated the occurrence of minimally symptomatic EBOV infection in quarantined contacts of reported Ebola virus disease cases in a recognized 'hotspot.'

Methodology/principal Findings: We conducted a cross-sectional serosurvey in Sukudu, Kono District, Sierra Leone, from October 2015 to January 2016. A blood sample was collected from 187 study participants, 132 negative controls (individuals with a low likelihood of previous exposure to Ebola virus), and 30 positive controls (Ebola virus disease survivors). IgG responses to Ebola glycoprotein and nucleoprotein were measured using Alpha Diagnostic International ELISA kits with plasma diluted at 1:200. Optical density was read at 450 nm (subtracting OD at 630nm to normalize well background) on a ChroMate 4300 microplate reader. A cutoff of 4.7 U/mL for the anti-GP ELISA yielded 96.7% sensitivity and 97.7% specificity in distinguishing positive and negative controls. We identified 14 seropositive individuals not known to have had Ebola virus disease. Two of the 14 seropositive individuals reported only fever during quarantine while the remaining 12 denied any signs or symptoms during quarantine.

Conclusions/significance: By using ELISA to measure Zaire Ebola virus antibody concentrations, we identified a significant number of individuals with previously undetected EBOV infection in a 'hotspot' village in Sierra Leone, approximately one year after the village outbreak. The findings provide further evidence that Ebola, like many other viral infections, presents with a spectrum of clinical manifestations, including minimally symptomatic infection. These data also suggest that a significant portion of Ebola transmission events may have gone undetected during the outbreak. Further studies are needed to understand the potential risk of transmission and clinical sequelae in individuals with previously undetected EBOV infection.
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http://dx.doi.org/10.1371/journal.pntd.0005087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112953PMC
November 2016

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone.

J Infect Dis 2016 10 28;214(suppl 3):S153-S163. Epub 2016 Sep 28.

Partners In Health.

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050485PMC
http://dx.doi.org/10.1093/infdis/jiw345DOI Listing
October 2016

Moving Towards a More Aggressive and Comprehensive Model of Care for Children with Ebola.

J Pediatr 2016 Mar 8;170:28-33.e1-7. Epub 2016 Jan 8.

Partners in Health, Boston, MA. Electronic address:

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http://dx.doi.org/10.1016/j.jpeds.2015.11.054DOI Listing
March 2016

Emergency department quality and safety indicators in resource-limited settings: an environmental survey.

Int J Emerg Med 2015 Dec 31;8(1):39. Epub 2015 Oct 31.

Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.

Background: As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings.

Methods: We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian's structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89.

Results: A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care.

Conclusions: The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization.
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http://dx.doi.org/10.1186/s12245-015-0088-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628609PMC
December 2015

Strengthening emergency care: experience in central Haiti.

Lancet Glob Health 2015 Apr;3 Suppl 2:S5-7

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Partners In Health, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2214-109X(14)70378-XDOI Listing
April 2015

A research agenda for acute care services delivery in low- and middle-income countries.

Acad Emerg Med 2013 Dec 27;20(12):1264-71. Epub 2013 Nov 27.

The Columbia University Mailman School of Public Health, Department of Population and Family Health, sidHARTe Program, New York, NY; The Department of Emergency Medicine, Columbia University College of Physicians & Surgeons, New York, NY.

Delivery of acute care services at every level of the health system is essential to ensure appropriate evaluation and management of emergent illness and injury in low- and middle-income countries (LMICs). The health services breakout group at the 2013 Academic Emergency Medicine consensus conference developed recommendations for a research agenda along the following themes: infrastructure, implementation, and sustainable provision of acute care services. Based on these recommendations, a set of priorities was created to promote and guide future research on acute care services.
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http://dx.doi.org/10.1111/acem.12259DOI Listing
December 2013

Back to the bedside: the 8-year evolution of a resident-as-teacher rotation.

J Emerg Med 2011 Aug 9;41(2):190-5. Epub 2010 Jul 9.

Division of Emergency Medicine, University of Washington, Seattle, Washington, USA.

Background: Teaching our residents to teach is a vital responsibility of Emergency Medicine (EM) residency programs. As emergency department (ED) overcrowding may limit the ability of attending physicians to provide bedside instruction, senior residents are increasingly asked to assume this role for more junior trainees. Unfortunately, a recent survey suggests that only 55% of all residencies provide instruction in effective teaching methods. Without modeling from attending physicians, many residents struggle with this responsibility.

Objectives: We introduced a "Resident-as-Teacher" curriculum in 2002 as a means to address a decline in bedside instruction and provide our senior residents with a background in effective teaching methods.

Discussion: Here, we describe the evolution of this resident-as-teacher rotation, outline its current structure, cite potential pitfalls and solutions, and discuss the unique addition of a teach-the-teacher curriculum.

Conclusion: A resident-as-teacher rotation has evolved into a meaningful addition to our senior residents' training, fostering their growth as educators and addressing our need for bedside instruction.
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http://dx.doi.org/10.1016/j.jemermed.2010.05.020DOI Listing
August 2011

Blunt cardiac rupture.

J Emerg Med 2010 Sep 1;39(3):337-40. Epub 2010 May 1.

Department of Emergency Medicine, North Shore Medical Center, Salem, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.jemermed.2010.03.020DOI Listing
September 2010