CE Gilbert Bonsu

BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH DEPARTMENT OF INTERNATIONAL HEALTH

CULMINATING EXPERIENCE COVER PAGE Name: Gilbert Bonsu CE Advisor: Dr. Kojo Yeboah-Antwi

Strengthen Emergency Medical Services (EMS) in Ghana to reduce disabilities and mortality due to disease with implications for EMS.

Abstract This policy brief examines the three components of emergency medical services (EMS) in Ghana by taking a look at the top causes of admission and death in Ghana hospitals for all ages, with implications for EMS. Data for analysis were collected from published reports, journal articles, email interviews, and Ghana’s Ministry of Health’s website. By examining these three components, areas of improvements were identified and recommendations were made on how Ghana’s Ministry of Health can strengthen emergency medical services in Ghana. The recommendations included: 1) training first responders and bystanders; 2) decentralization of the National Ambulance Services (NAS) ; 3) embarking on a mass media campaign to promote NAS; 4) establishing a national triage scale for all healthcare facilities. Strengthening of these areas of Ghana’s emergency medical system will aid in reducing maternal mortality due to obstetric emergency and disabilities and mortality due to road crashes. Key Words: Emergency Medical Services, EMS, Ghana, Triage CE Advisor: Date:

2 Culminating Experience

Table of Contents

INTRODUCTION ................................................................................................................................................... 3

COMPONENTS OF EMS ...................................................................................................................................... 3

GHANA ..................................................................................................................................................................... 4

GHANA’S EMERGENCY MEDICAL SERVICES: ........................................................................................... 5

RECOMMENDATIONS ........................................................................................................................................ 7

CONCLUSION ......................................................................................................................................................... 8

BIBLIOGRAPHY: ..................................................................................................................................................... 11

MEMORANDIUM

Date: December 19, 2012

To: Ghana Ministry of Health

From: Gilbert Bonsu

RE: Strengthen Emergency Medical Services in Ghana

INTRODUCTION The Ghanaian government, after events such as the May 9

th Accra Sports Stadium disaster, in

which 126 lives were lost, took a step to form the National Ambulatory Service (NAS) to provide

emergency medical service.

The purpose of emergency medical services (EMS) is to stabilize patients who have a life-

threatening medical condition whether through injury, infection, obstetric complication, or

chemical imbalance in a timely manner by the best possible means to control morbidity, prevent

disability, and enhance survival (1–3).

Although having a medical-transport system is a crucial component in providing emergency

medical services, EMS functionality consists of three interdependent components. These three

components are; 1) pre-hospital care at the site of injury/medical emergency, 2) care during

transportation, and 3) health facilities care (1,2). It is critical that each component works together

to control morbidity, prevent disability, and enhance survival.

This policy memo will begin with reviews of the three components of EMS and it will take a look

at the top causes of admission and death in Ghana hospitals for all ages, especially those with

implication for EMS. Next, an analyzes of Ghana’s emergency medical services would be

provided with specific attention to efficiencies of healthcare facilities, pre-hospital and hospital

triage guidelines, and ambulance services. Based on the above mentioned analysis,

recommendations will be made in areas where Ghana’s Ministry of Health can strengthen its

emergency medical services system. Strengthening of Ghana’s EMS system will help the country

reach its MDG goals for 2015 due to the number of diseases and mortality that has implication for

EMS.

COMPONENTS OF EMS In an ideal emergency medical system, all three components of emergency medical services are

present and work hand-in-hand. Pre-hospital care encompasses the care at the scene of

injury/medical emergency (home, school, work, recreation area, or other location) until the

patient arrives at a formal health care facility capable of providing the needed care (1,4).

Pre-hospital care involves site management, alerting the appropriate personnel for medical

transport, and preparing the patient for transport. This level of care can be performed by providers

with varying levels of training and skills. The three common levels of pre-hospital providers are

first responders (trained lay responders), Emergency Medical Technician (EMT), and paramedics.

First responders and EMT provide Basic Life Support (BLS) whereas care delivered by

paramedics is known as Advance Life Support (ALS) (1,5,6).

Care during transportation is a critical part of pre-hospital care (1,4). Emergency transportation

should be accessible in a short period of time and economical (4). In areas with formal EMS


system, transportation is provided by dedicated ambulances with basic and advanced life support,

whereas in a location with the informal EMS system, commercial vehicles, private cars,

motorcycle, or the police brings the patients to the health facilities (1).

Care in healthcare facilities is the third component of an emergency medical service where

appropriate definitive care is delivered upon arrival (1,4). The capability of health facilities varies

with respect to equipment, type of staff, and resources. Nevertheless, every health facility should

be available to provide some degree of emergency care (2,4).

GHANA

Ghana, a country of 23.8 million in population, is divided into 10 political regions with 138

decentralized districts. The population density in the country varies depending on the region. It is

sparse in the northern half of the country, which also happens to be the poorest economically, and

dense in the southern part of the country. Life expectancy from birth in Ghana is 60 years (7,8).

The maternal mortality rate in Ghana is 350 deaths per 100,000 live births (7). The delay in

reaching health facilities for obstetric emergency situations are key contributors to the high

maternal mortality (9). Obstetric emergencies are unique as care on-site, during transportation,

and in health facilities must be provided for two people, the mother and the fetus. Obstetric

emergencies can result from preterm labor and delivery, premature rupture of membranes, severe

preeclampsia, and prolapsed umbilical cord (10).

Changes in demographics and lifestyle have been accompanied by a change in the epidemiology

of morbidity and mortality in Ghana. Reckless driving is also a major contributor to the change in

morbidity and mortality in Ghana (11). Road traffic accidents continue to increase as the

population and urbanization grows. The number of registered vehicles in Ghana rises annually.

Table 1 provides summary statistics on road crashes in 2006 and 2007. The number of road

crashes increased by 3.2% from 2006 to 2007. Both fatalities and serious injuries increased from

2006 to 2007, 10.1% and 6.9%, respectively. Many survivors of road accidents eventually die due

to late emergency response and improper care at the injury site (12).

Table 1: Summary statistics of road crashes in 2006 and 2007. Data Category 2006 2007 % Increase/ (Decrease)

# of registered vehicles 841,314 932,540 10.8

Total # of crashes 11,668 12,038 3.2

Fatalities 1,856 2,043 10.1

Serious Injuries 5,882 6,287 6.9

Fatalities per 100 crashes 15.9 17 6.9

Rural/Urban Casualty ratio 9,284/7,074 8,802/7,611 (5.2)/7.6

Male/Female Fatality Ratio 1,348/492 1,554/489 15.3/(0.6)

Source: Ghana Road Safety

An effective emergency care system can mitigate morbidity and mortality and obstetric

emergencies in Ghana (1).

GHANA’S EMERGENCY MEDICAL SERVICES

Theoretically, the core components of Ghana’s EMS are care in the community/first responder

system, pre-hospital emergency care, and hospital emergency services. The objectives of Ghana’s

EMS are:

Reduce delays in getting to a health facility

Reduce delays in getting appropriate health care

Make pre-hospital emergency services readily available to all those in need

Provide a continuum of care for emergency cases from site of emergency to health

facility level

Increase the number of institutions with trauma care systems that maximize survival and

functional outcomes of trauma patients and help prevent injuries

Increase the number of districts that have implemented guidelines for pre-hospital and

hospital emergency care (9)

Pre-hospital Care: Pre-hospital care is informal in Ghana. When injury occurs at home, family members or

neighbors are usually the first people on site. From personal communications with people in

Ghana, most of these first responders are not trained in injury site management; how to prepare

patients for transport; and some do not know what number to call for the ambulance. Most deaths

from injuries occur immediately after the injury (50%), 30% within four hours, and 20% after the

event that causes the injury. Frequently, these injuries are treatable condition and deaths occur as

a result of airway compromise, respiratory failure, or uncontrolled hemorrhage (5,13).

The critical task required of a bystander/layperson outlined by in the WHO’s pre-hospital trauma

systems during an event of injury or medical emergencies are: getting involved; calling for help;

assessing the safety of the scene; assessing the victim; providing immediate assistance; and

securing essential equipment and supplies (5).

Through email interview, it was realized that in Ghana when injury or medical emergencies

occur, bystanders usually decide to get involved. They also call for help, usually to the police, fire

department, and commercial or privately owned vehicles for transport to health facilities.

Bystanders’ knowledge and skill make their decision to get involved beneficial or detrimental to

the victim. Most bystanders in Ghana are not trained in how to manage the site of injury to

prevent additional injuries to the victim and themselves. They lack basic skill in assessment and

may not recognize medical conditions as emergency and provide immediate assistance to avoid

risk of death or disability. The lack of access to equipment such as bandages, gloves, masks, etc.

can pose as a potential risk in the case of infectious diseases.

A study in Ghana that trained 335 commercial drivers using a six-hour basic first-aid course

confirms that such reported that improvement in the process of pre-hospital trauma care can occur

through these personnel. Appendix B displays a table of the components of the six-hour basic

first-aid course and results (1).

Care during transportation:

Ambulance services in Ghana are fragmented and lack effective and efficient coordination. The

main ambulance services in Ghana are the newly structured National Ambulance Services (NAS),


Hospital Ambulance Services maintained by the Ghana Health Services, the Fire Service

Ambulance Service (FS), and Private/ Non-governmental Organizations (NGO) Ambulance

Services such as St. John Ambulance and First Intervention Ghana (14).

The NAS is an important part of the Ghana’s EMS. NAS was established in 2004 as an agency of

the MOH in collaboration between the Ghana National Fire Services of the Ministry of Interior.

The core mandate of NAS is to provide efficient and timely pre-hospital emergency medical care

to the sick and the injured and transport them safely to health facilities (15). NAS operates in

every region in Ghana with 51 stations and 2 control rooms (16). The NAS also provides stand by

emergency cover at mass public meetings and liaise with other emergency services in time of

disaster or mass casualty incidents. It assists in the formulation and implementation of programs

for first respondents and in the establishment and operation of makeshift hospitals during mass

casualty situations (16).

A 2007 audit report on road safety in Ghana that reviewed the NAS showed that the two major

problems facing the NAS were fuelling issues due to inadequate and the late arrival of fuelling

coupons and the absence of ambulance maintenance services in regions due to the centralization

of the maintenance services (12).

The national ambulance services are fees for service and available in all of Ghana’s ten regions

but it is relatively unknown to the masses. Most people knew the fire service ambulance and

hospital ambulances that transfer patient from one healthcare facility to another. Majority of them

preferred a taxi or private owned vehicle as a means of transport to the healthcare facilities in

case of emergencies and thought these means were swifter. The few who knew about NAS,

however reported that the EMT were professional and seemed well trained (interviews).

Care at Healthcare Facilities:

Triage, the process of screening patients to determine their relative priority for treatment and

transfer is an important procedure in emergency medical services (4). Triage is important as it

identifies patients at risk, especially people who do not look sick, for treatment in a timely

manner (triage lecture). A study that compared Ghana, Mexico, and the USA found that mortality

could be decreased if pre-hospital and emergency room care are improved. This study also

reported that scene time was longer in lower income areas thus contributing to the high mortality

in pre-hospital deaths compared to high income areas (13). Having a national triage system can

help reduce the high mortality from emergency room care such as the prolonged time (mean of 12

hours) to emergency surgery at a main hospital in Kumasi (17).

The World Health Organization (WHO) assessment of quality of care for children in selected

hospitals in Ghana concluded that emergency care system was not well established and there were

no triaging systems in these hospitals. The assessment also stated that there was a lack of

protocols and guideline for in-patient care of childhood conditions thus affecting the treatment

and monitoring of diseases (18).

A cross-sectional study by Norman et al. between March – June, 2010 that evaluated the basic

logistical assets preparedness of 22 Ghana hospitals for emergency intervention confirmed the

WHO assessment. The study found that hospitals lacked pre-emergency and emergency

preparedness, and coordination of hospitals response mechanisms was poor. The study indicated

that the triage standards in the Ghana Health Services (GHS) was flawed because it did not cover

on-site management and only covered minimal in-hospital ER operations (19).

RECOMMENDATIONS Ghana’s emergency medical services are in its infantile stage for a formal system. Although

improvements are being made in transforming EMS in Ghana from an informal to a formal

system, efforts should be made to strengthen the informal system, knowledge, and skill

laypersons.

1. Care at site of injury

Training of bystanders/first-responders: The MoH, GHS, or NAS should train first-

responders/bystanders in the critical tasks required by these individuals when an emergency

event occurs. Volunteers for this training course can be sought from bus/taxi stationmasters

alongside selected drivers, marketplace queens, and teachers since they are likely the first at

an injury scene.

The training course should include scene management, airway management, bleeding control,

splint application, primary survey (using the ABCs method for evaluating life threatening

injuries), moving causalities, phone numbers to appropriate authorities to contact, and

universal precautions (1,20). The national ambulance services EMT training instructors can,

with help from the Red Cross, conduct this course. Gifts in-kind, such as transportation to the

course and lunch during the training can be offered. Volunteers should also be provided a

basic first aid kit to keep on-site.

2. Care during transportation

Fuelling & Maintenance of NAS vehicles: The Ministry of Health should decentralize the

national ambulance services to avoid issues such as vehicles not being available because they

are sent for repairs in the country’s capital and lack of fuelling coupons. The MoH should

equip each regional headquarters maintenance facilities with the capacity to service these and

give it the authority to generate and issue fuelling coupons to ensure that vehicles are always

in the region and in an operating state.

Knowledge of the National Ambulance Services: The MoH should embark on a mass media

campaign to inform people about the national ambulance services and the services they

provide. This media campaign and stakeholder meetings should also be used as a platform to

help people distinguish between NAS and the police/fire ambulances; explain why it is much

safer for injured persons to be transported by ambulance; and for all persons to respect and

yield way for ambulances when in transport.

3. Care at Healthcare facilities

Poor quality of care at health facilities can deter community members from seeking care even

in emergency situations. One way to strengthen health facilities handling of emergency care

in Ghana is establishing a national triage scale for all levels of healthcare facilities (both

private and government owned). The Emergency Triage Assessment and Treatment (ETAT)

by the WHO’s Integrated Management of Childhood Illness strategy can be used as a guide to

develop a standard triage in-and-out hospital regime for all hospitals.

Establishing a national triage scale can be relatively inexpensive but will need strong political

backing and resolve from the Ministry of Health and hospital management groups (19).


CONCLUSION As Ghana makes the transition from informal emergency medical services to a formal system, it

should take a calculated approach that ensures that all citizens can receive services. The MoH and

its service arm, GHS, should seek to improve all the core components of EMS. If pre-hospital

care at the site of injury and transportation is poor, deaths that could have been prevented occur.

On the other hand, if quality of care at health facilities is poor and leads to death, it neglects the

efforts of the first two components of EMS and the community may be discouraged from taking

patients promptly to health facilities even when transportation is available (1,4).

Ambulance services may not be the best solution presently for all areas in Ghana. Trained lay

responders can provide cost efficient and effective care at the site of injury and during transport in

these areas. It is important for laypersons are trained to aid EMTs as some areas in Ghana are in

need of accurate maps, house numbers, street names, and road signs. These elements make it hard

for an ambulance to easily reach a patient and elongate response times (1).

It is also crucial that the Ghanaian populations are aware of services by NAS as the country seeks

to move from an informal EMS system.

APPENDIX A: Providers of Pre-Hospital Care

Basic Life Support includes interventions that are non-invasive such as CPR, oxygen

administration, full immobilization and puts emphasis on transport to healthcare facilities.

Advance Life Support consists of all BLS interventions as well as providing intravenous (IV)

therapy, needle-chest decompression, and admission of control medications(21).

First-Responders: First responders are community members such as taxi drivers who have been

taught basic first aid techniques and are able to recognize threatening conditions. Some first

responders, known as the “advanced first-aid providers” are taught the principles of rescue, limb

immobilization, and how to prepare patients for transport. First responders training programs

usually lasts for a few hours (5).

EMT: EMTs are a group of EMS providers who have been trained in trauma care and thus have

knowledge and skills beyond those of first responders. EMTs skills include airway management,

applying oxygen, CPR, control of shock and bleeding, and more patient assessment. There are

two categories of EMT personnel, EMT-Basic and EMT-Intermediate. EMT training is general

about 100 to 400 hours long (5).

Paramedics: Paramedics are trained in all of EMT skills as well as administering intravenous

medications, using advanced airway adjuncts, IV therapy, and other wide range of injury and

acute diseases management. Paramedics are trained for thousands of hours in the classroom and

on the field (1,5).


Appendix B: Improvement in the provision of the components of first aid in comparison to

what was reported before the course.

Table 2

Components of first aid Before (percent) After (percent) Crash management 7 35

Airway Management 2 35

Bleeding control 4 42

Splint application 1 16

Triage 7 21

Source: Mock and others 2002

Table 3: Cost & Length of Study Cost $ 3 per participant

Length of study 10.6 months

Source: Mock and others 2002

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