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

Importance: Investments in emergency care systems are vital to ensuring universal health coverage and improving health outcomes in low- and middle-income countries. Objective: To assess whether a package of emergency care interventions is associated with improved patient mortality and clinical care quality. Design, Setting, and Participants: 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. Interventions: Triage, standardized documentations, and clinical teaching via a formal curriculum and bedside clinical mentorship. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.