# Implementation of a Package of Emergency Care Interventions and Clinical Outcomes

## TL;DR

A set of low-cost emergency care interventions in Liberia significantly improved patient outcomes and reduced early mortality.

## Contribution

Demonstrates that low-cost emergency care interventions can significantly reduce mortality in resource-limited settings.

## Key findings

- Implementation of the intervention package was associated with a significant reduction in 24- and 48-hour mortality.
- In-EU mortality decreased significantly during the program implementation period.
- Multivariable analysis showed the adjusted odds of death were halved during the intervention period.

## Abstract

Is a package of quality improvement interventions associated with improved clinical outcomes in a resource-limited setting in Liberia?

This quality improvement study of 344 preimplementation patient encounters compared with 1073 enrolled during program implementation found that implementation of a package of low-cost interventions was associated with improvements in emergency care quality and significant reductions in early death.

These results suggest that prehospital and emergency unit mortality in this setting accounts for a substantial proportion of overall mortality in the health system, and low-cost interventions have the potential to lead to significant immediate and sustained improvements in both emergency unit quality and patient mortality.

This quality improvement study assesses whether the implementation of a package of emergency care interventions, as piloted at a single hospital in Liberia, was associated with improved clinical care quality.

Investments in emergency care systems are vital to ensuring universal health coverage and improving health outcomes in low- and middle-income countries.

To assess whether a package of emergency care interventions is associated with improved patient mortality and clinical care quality.

This pre-post quality improvement study was conducted at a single urban referral hospital emergency unit (EU) in Monrovia, Liberia, to assess clinical and educational outcomes resulting from the implementation of a package of interventions from January 1, 2018, through June 30, 2019. Final analysis was performed in November 2023. Data from a random subset of adult patient encounters were collected retrospectively for the 12 months and compared with all adult patient presentations to the EU during the 6-month program implementation.

Triage, standardized documentations, and clinical teaching via a formal curriculum and bedside clinical mentorship.

The primary outcome was all-cause mortality within 24 hours. Secondary outcomes included mortality at 48 hours, in-EU mortality, and EU quality process indicators. Multivariable logistic regression models were constructed to compare the association between program implementation and all-cause mortality.

A total of 344 preimplementation patients were compared with 1073 patients enrolled during the program with largely similar baseline characteristics between the 2 groups (mean [SD] age, 41.4 [16.4] vs 40.1 [17.3] years: 178 [51.7%] male and 164 [47.7%] female vs 601 [56.0%] male and 472 [44.0%] female; and 163 [47.3%] vs 510 [47.5%] near a hospital). All-cause mortality at 24 and 48 hours was significantly different between the preimplementation and implementation periods (27 [8.3%] vs 40 [3.9%], P < .001, and 34 [10.4%] vs 52 [5.0%], P < .001, respectively). In-EU mortality was significantly different between the 2 groups (13.5% [44 of 327] vs 7.1% [73 of 1031], P < .001). In multivariable regression, the adjusted odds of death at both 24 and 48 hours among patients in the intervention period was half that of the preintervention period.

This quality improvement study provides evidence that a set of interventions is associated with improved emergency care quality and reduced mortality. The high rates of EU-based mortality suggest the critical need to include EC in all facility-based quality improvement efforts.