Transcript An ambulance referral network improves access to emergency

An ambulance referral network- does it improve
access to emergency obstetrics?
Tayler-Smith K, Zachariah R, Manzi M, Van den
Boogaard W, Nyandwi G, Reid T, De Plecker E,
Lambert V, Nicolai M, Goetghebuer S, Christiaens B,
Ndelema B, Kabangu A, Manirampa J, Harries AD
Médecins Sans Frontières
Burundi Ministry of Health
International Union against Tuberculosis and Lung Disease
London School of Hygiene and Tropical Medicine
Burundi
Background - Burundi
• High maternal mortality ratio – 800 maternal deaths
/100,000 live births (200x more than in Sweden)
• High neonatal mortality – 42 / 1000 live births
(20X more than Belgium))
• Main reasons: Poor access to and availability of
Emergency Obstetric and Neonatal Care (EmONC)
• Since 2006, MSF has managed an intervention in rural
Burundi including setting up a referral system
MSF intervention
 Emergency Obstetrics and
Neonatal Care (EmONC)
facility
 Emergency patient transfer
service from peripheral
facilities → hospital
Research question

Does an ambulance referral network effectively
improve access to emergency obstetrics and
neonatal care?
Study objectives
1) Describe the ambulance &
communication system
2) Assess the association
between referral times and
maternal & neonatal deaths
3) Describe the cost of the
referral system
Study setting: Kabezi district
• Population ~ 198,000
• ~9900 expected deliveries/yr
• One district hospital
• 9 health centre maternities:
1-70km from hospital
Location of the district’s maternities
covered by the referral network
o 4 on the main road
o 5 on hillside dirt
tracks
o Furthest centre:
3 hours away
o Altitudes: 800 – 2000
meters
.
Communication & ambulance network
(24 hours, all days)
• Referral criteria:
At risk deliveries/Obstetric complications
• VHF Radio
• Three ambulances
(3 health districts)
Referral criteria to CURGO
At risk for complicated delivery
•
•
•
Previously > 5 deliveries
First pregnancy and height < 1.5m
History of obstetric fistula
Obstetric Complications
•
•
•
Complication of abortion
Mal presentation of foetus
Post partum haemorrhage
Communication system –
VHF Radio
• 8 maternities use VHF
for calling an
ambulance
• 1 MU uses a cell phone
Communication system –
Radio operator
o Records all
incoming calls
o Passes on to medical
transfer team
o Criteria met;
ambulance goes out.

Communication system –
Ambulance driver
o Keeps in contact with
maternity and CURGO
o Records arrival/departure
time at/from MU

The ambulance
Equiped with emergency
medication / tools including
oxygen, reanimation drugs
+ equipment.

The ambulance transfer nurse
o Nurse trained in obstetrics
evaluates the patient at the
maternity and confirms
diagnosis made by the
maternity nurse
o Observes and provides
essential care to the patient
during transfer until arrival at
hospital
Data Sources
Data sources
Ambulance call books
Logistic records
Hospital medical database
Study period
Jan – Dec 2011
Ethics
Burundi Ethics Committee & MSF
Ethics Review Board
Median time: call out to dispatch
and return
Total ambulance call outs
Maternity call – Ambulance dispatched*
Ambulance dispatch – Roundtrip to hospital*
* for 86 occasions time unknown
1478 for
1385 women
30 min
IQR(15-65)
78 min
IQR (52- 130)
Main Reasons
Other
18; 19%
Abortion
21; 22%
Risk Miscarriage
6; 6%
Previous C section,
16, 16%
Excessive height of
uterus; 6; 6%
Rupture of
membranes
8; 8%
Abnormal
presentation
8; 8%
Prolonged
obstructed labour
15; 15%
Referral times in association with early
adverse neonatal outcomes
Ambulance call –
return to hospital
< 3 hours
> 3 hours
Unknown
Hospital
deliveries
Neonates
Stillborn & Death
< 24hrs after birth
n (%)
840
858
75 (9)
136
137
21 (15)
57
57
8 (14)
Referral times > 3 hours associated with significant higher risk
of neonatal death: OR 1,9; 95% CI, 1.1-3.2) P-value: 0.02
Only 1 maternal death
Transport Costs
Costs in Euros
Vehicles (Toyota land Cruiser)
Stretcher and oxygen on board ambulance
Drugs on board ambulance
Vehicle tax and insurance / year
Vehicle repair and maintenance / year
Fuel / year
Drivers – gross salaries
Accompanying nurses – gross salaries
Total
Annual costs
10 008
485
3619
1291
3968
12414
17976
20585
70 346
Communication Costs
Costs in Euros
Radio system
Radio operators – gross salaries
Radio VHF kits for the health centres
Solar panel kits for the health centres
Ambulance radios
Total
Annual costs
200
12 732
540
1 672
96
15 240
Costs - per case & capita
Costs in Euros
Communication total
Transport total
Total
Cost per obstetric case: € 61
Cost per capita / year: € 0.43
Annual costs
15 240
70 346
85 586
Conclusion
o A medicalised ambulance was
key to starting care early
o Strong association between
referral time and early neonatal
death – this needs to be reduced
o Overall per-capita costs are low
o Motorbike ambulances ?
Acknowledgements
Many thanks to the patients and clinical staff at Kabezi hospital
and maternities and to the relevant Health authorities
Luxor Operational Research Team