Introduction

In Ethiopia, modern medicine began to develop during the reign of Menelik II (1865–1913). The Russian Red Cross mission in 1896 established the first hospital, The Russian Hospital, with the aim of treating soldiers injured during the Ethio-Italian War (the Adwa war). In 1906, the Russian Red Cross left Ethiopia and the hospital came under government control. This hospital was renamed after Menelik II [1–3]. Over the coming years, health centers were established throughout Ethiopia to provide primary outpatient and minimal inpatient services to the surrounding population. However, the majority of patients lived in rural areas with their closest health center often greater than 10 kilometers from the referral hospital and they had no access to motorized transportation. As a result, most of the population had little to no access to emergency care or appropriate diagnostic equipment [4].

In the past two decades, the Federal Ministry of Health (FMOH), the Addis Ababa City and Health Bureau, and Addis Ababa University School of Medicine have spearheaded initiatives to improve emergency care, strengthen human resources through training and education, and establish emergency care systems in the country. Concrete achievements include emergency medicine graduate programs and short-term training programs, as well as the development of prehospital ambulance programs [5]. Appropriate schooling and training paves the way for standardized emergency care systems. Standardized emergency care systems have demonstrated improved patient outcomes [6] and, therefore, have an important role in improving population health and should be a priority for local policy makers. As a result, the organizations mentioned above have recommended standards which have been established by the Ethiopian Standards Agency. However, not only are many of these endeavors still in their infancy, but none of these initiatives arose from a formal gap analysis to compare the services currently available to the resources needed to adequately serve the population.

In order to further strengthen emergency care, eight years ago the FMOH established a subdivision named the Emergency and Critical Care Directorate (ECCD) that was tasked with developing and standardizing emergency care. Despite this tremendous step forward in prioritizing emergency care, the ECCD has limited enforcement and legal mandate to ensure compliance with standards, a power which was traditionally held by the Ethiopian Food and Drug Authority. Therefore, the ECCD would benefit from a close partnership with this regulatory body.

In 2016, the ECCD built a task force to evaluate the state of emergency medicine in Ethiopia. This task force consisted of local clinicians, academicians and policy makers. The major objective of this task force was to evaluate the current emergency care capacity in major hospitals by performing a gap analysis. According to a search of the FMOH’s library of data, this investigation is the first nationwide emergency and trauma gap analysis that has been conducted and published. The information obtained from this assessment will be critical for appropriate resource allocation and strengthening of the current emergency units.

Methods

This is a cross sectional investigation that utilized convenience sampling of twenty-two hospitals consisting of primary, general and tertiary hospitals (see Table 1). This study was part of MOH’s quality improvement initiative and thus no IRB consent was obtained. See the letter attached from MOH for confirmation. Verbal consent was obtained from participants. This was to assure that all participants were kept anonymous. The main survey that was used was based off of Columbia University’s sidHARTe Program Emergency Services Resource Assessment Tool (ESRAT) [7]. It was originally developed by Columbia University to assess for emergency care capacity in Rwanda and Ghana. Over a period of three weeks, an ECCD task force composed of general surgeons, neurosurgeons, and emergency physicians expanded upon ESRAT to include a trauma evaluation and called it ETSRAT-Ethiopia (See S1 Appendix). ETSRAT-Ethiopia is the main tool used for this study.

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Table 1. List of hospitals assessed in the study (Sources: Ethiopian Standards Agency).

https://doi.org/10.1371/journal.pone.0258310.t001

Twelve interviewers consisting of physicians and nurses from various medical fields were trained by emergency physicians on how to use the ETSRAT-Ethiopia and conduct the four-hour interview. The interviewers worked in teams of two, with each pair consisting of at least one nurse or physician that specializes in Emergency Medicine. Each pair would visit a hospital and interview hospital administrators and emergency care area personnel using the ETSRAT-Ethiopia survey mentioned above. Initially, three hospitals were piloted in the capital of Ethiopia, Addis Ababa, during the first week. A further revision was made to the tools based on feedback from the pilot assessments. Using convenience sampling, a total of twenty-two hospitals were evaluated across seven regions of Ethiopia using the further revised ETSRAT-Ethiopia tool.

The findings were tabulated using Microsoft Excel Professional Plus 2016. One member of the pair reviewed each result from the survey and verified the recorded answers with the tabulated results. Based on these results, two reviewers calculated the proportion of hospitals where each parameter was measurable. Furthermore, the reviewers used the findings of ETSRAT-Ethiopia to then retrospectively assess how the baseline status compared against two established standards: the World Health Organization’s Essential Package of Emergency Care (EPEC), as well as the Ethiopian FMOH’s standards. EPEC defines a series of essential functions that are needed for an emergency care system to function completely and efficiently, and consists of components such as medications, equipment, and procedural skills (See S1 Appendix).

Results

Discussion

The results of this investigation show both promising trends as well as areas for improvement regarding the access and infrastructure of EUs, emergency medicine triaging systems, training in emergency medicine, equipment and procedures in the hospitals, and disaster management.

It was encouraging to find that all the hospitals surveyed were operational 24 hours a day. However, the ratio of the population to EUs is suboptimal as the WHO recommends the physician to population ratio to be 1:1000 [11] but over a quarter of the hospitals surveys covered catchment areas of over 5 million. With respect to patient transportation, 77% of hospitals reported at least one ambulance available, which is in line with the ECCD’s target objectives of increasing ambulance converge from 70% to 100% [5].

The water availability in the hospitals is an area of dire concern given the need for clean water in basic sanitation, prevention of infectious pathology, and delivering of medical care. Water access objectives have been established by the WHO through the Sustainable Development Goals (SDGs) which aims to, “by 2030, achieve universal and equitable access to safe and affordable drinking water for all” [12]. This investigation revealed that across the 22 hospitals surveyed, only 36% had reliable coverage, while 59% reported unreliable coverage. This is consistent with the countrywide coverage of 55%. Ethiopia’s progress as a country thus far has been such that the proportion of the population that lacked access to water dropped from 74.4% to 45% [14] in 2015.

It is also concerning that across hospitals electricity availability was not a guarantee, making it questionable whether basic hospital actions were able to be performed at any given time. However, compared to water, the availability of electricity was more reliable with 64% reporting always having access, and 32% reporting sometimes having access. Universal access to energy is listed as a SDG with the goal by 2030 to achieve “universal access to affordable, reliable and modern energy services” [12]. According to the World Bank, Ethiopia’s electricity access was 12.7% in 2000, 33.1% in 2010, and 44.9% in 2018 [13]. Based on this information, it took Ethiopia roughly twenty years to triple electricity availability. With current projects underway like the Grand Ethiopian Renaissance Dam, it is possible for the country to make great strides in coverage. If the country is able to double its coverage in ten years, then coverage can reach an astonishing 90% by 2030.

This investigation has revealed that the design of triage and resuscitation areas varies greatly among hospitals surveyed leading to questionable uniformity in delivery of appropriate and timely emergency medical care. This is despite the standards set up by the Ethiopian Standard Agency (ESA) (see Figure III in S1 Appendix). All hospitals reported availability of EUs to deliver emergency services, but EUs were often not the sole site of emergency and resuscitation activities. While nearly all hospitals reported that medical and surgical patients were triaged in the EUs, for pediatric and OBG patients, less than one third of hospitals reported triaging them in the EUs. Instead, these patients were triaged in an “area for this specific patient population”. When examining the responses about resuscitation designation, though the majority of hospitals resuscitated medical-surgical patients in the EU, less than half of hospitals resuscitated pediatric and OBG patients in the EU. Similarly to the triage systems, pediatric and OBG patients were most likely to be resuscitated in the STRA.

While this may not create complications when considering inter-hospital transfers, it may very well create variations in the quality of care across hospitals. For example, providing emergency care in different areas such as in the outpatient or inpatient wards could lead to a delay in providing timely care for acutely ill patients. Several studies from low-middle income settings have shown that identifying acuity early and instituting appropriate therapeutic intervention early and rapidly reduces hospital mortality [14, 15].

Emergency training is a vital issue in Ethiopia. Even though Ethiopia is one of the few countries that has an established Emergency Medicine specialization in Africa, most regional and district hospitals do not have nurses or doctors trained in Emergency Medicine. Overall, less than 50% of the surveyed hospitals had one or more Emergency Staff members that were trained either in ETAT, BLS, or NIEM. The results also show that the better resourced referral and general hospitals had more trained individuals. Moreover, the hospitals with Emergency medicine specialized nurses or doctors were more likely to have written guidelines and quality assurance methods. It is essential, to further the practice of emergency medicine, that all hospital staff associated with the EU area be trained appropriately to assure the proper delivery of emergency medicine care.

At a primary and general level, few EUs have functional equipment for management of airway and continuous monitoring. But almost all primary and general level facilities in this evaluation had intravenous fluids, nasal cannula and bag valve masks. At a tertiary level, most EUs have functional equipment for management of airway and breathing. Only some of the tertiary level facilities have continuous monitoring. But almost all of the tertiary level facilities have intravenous fluids and vasoactive agents. The evaluation of the essential equipment for triage purposes has shown that though wall clocks, stethoscopes and blood pressure cuffs were the most widely available resources, more than 40% of the hospitals did not have thermometer, glucometer or pulse oximetry at the triage stations. None of the hospitals surveyed reported having antifungals, antimalarials, or antihelminthic thought most had at least one type of antibiotic. Hypertonic saline, thrombolytics, and transfusion products such as FFP were also not present in the majority of hospitals, leading to concerns in their management of basic emergent conditions such as stroke, myocardial infarctions, trauma, and shock.

Some studies have shown that most district and regional hospitals in low and middle income countries (LMICs) have drugs and equipment necessary for providing basic emergency care but not for advanced care [15–17]. This does not hold true in our case with our data showing that, not only is basic equipment lacking, but also human resources, training and quality assurance methods. Though most hospitals reported having written guidelines, over 70% of the hospitals did not have written guidelines available at the time of survey. Written guidelines alone might not improve patient outcomes but they have been shown to improve patient care when introduced “through a multifaceted approach, targeting knowledge, motivation, resources and organization of care” [18, 19].

Even though disaster preparedness is an important aspect of emergency and trauma care, many facilities lack a formal disaster management plan. More than 75% of the hospitals reported lack of disaster preparedness and guidelines. Only 14% of the hospitals had an alarm system to alert other departments in cases of mass casualty incidents. It is essential that these gaps and others be further studied and tangible, targeted goals be set for improvements in emergency care delivery.

Limitations

The sample size of twenty-two public hospitals is the main weakness of this assessment, limiting the generalizability to the whole country. These hospitals were selected by convenience sampling, and are most likely to represent the best-resourced public hospitals in the country. Furthermore, in urban settings, most of the population seeks medical care in private institutions, which were not included in this assessment. Therefore, future assessments should be expanded to include more hospitals and employ random sampling of the facilities.

In regards to procedures, the assumption was made that if the equipment was present in the hospital, then the providers knew how to implement it appropriately. We understand this may be a limitation as assessing for procedural competency was beyond the scope of this study. Also, when discussing whether medications such as IV fluids, benzodiazepines, or paralytics are present, it is important to note that whether the hospital had more than one medication within the given category was not asked.

Conclusion

The latest research in our field has shown the incredible importance proper emergency medical care plays in improving the morbidity and mortality of a population. As a result, in the last few decades, policymakers in Ethiopia have made the development of Emergency Medicine a necessity. The first step in assuring an appropriate system is created is to do a gap analysis. Our gap analysis has revealed numerous inconsistencies in health care practice, resources, and infrastructure within the scope of Emergency Medicine in Ethiopia. Major gaps were identified, and the results of this assessment were used to devise action priorities for the Ministry of Health. Much remains to be done to strengthen Emergency Medicine in Ethiopia, and numerous opportunities exist to make additional short and long-term improvements.

Supporting information

Acknowledgments

We want to thank Dr. Rachel Moresky of sidHARTe Columbia for providing the tools to assess the hospitals.

We want to appreciate the staff at the Ministry of Health, St. Paul Millenium Hospital and Tikur Anbessa Specialized Hospital Emergency Department for their time revising and contextualizing the assessment tools.

We would also like to thank Mesfin Bekele, Mekdes Tati, and Tolesa Dida.