Assignment site:
Tegucigalpa, Honduras and San Salvador, El Salvador
1. Introduction
Armed violence is a major public health concern in Central America. With an average homicide rate of 38.6/100,000 in 2019, it surpasses WHO’s definition of an epidemic (>10/100,000). HON and SAL have the highest rates (41.2/100,000 and 36/100,000 InSight 2019). Still, the quality of the information available on violence is poor, making it difficult to measure the burden of deaths, injuries and disabilities at prehospital and health structures, or to estimate inverse lethality rate (# of causalities v. # of wounded).
In El Salvador, prehospital emergency care continues to be, in theory, under the responsibility of the MoH through its Medical Emergency System (SEM), but in practice the service remains decentralized. SEM only operates in urban areas and is ignored by all ambulance services including the SRC, which keeps its own call center. In each area, different ambulance providers operate with their own capacities, yet lack equipment, human resources and training. Ambulance services don’t have access to heavy violence-affected communities, so the Police acts as first-aid providers with very limited technical capacity. For first-aid posts and primary-health facilities, the situation varies according to the control exerted by armed groups in surrounding territories.
In 2020, Honduras ranked as the most violent country in Central America and third most dangerous in the Americas according to the Global Peace Index, with most victims of homicides being young men between 20 and 24 years old in the biggest cities (Tegucigalpa and San Pedro Sula)
The general health status of the Honduran population is worrisome; chronic and infectious diseases (including COVID-19), issues such as under-nutrition and a substantial number of accidental trauma and violence related cases are a heavy burden for the population. This coupled with a lack of access and a structurally weak health care system is resulting in a very troublesome general health status.
Since 2017, ICRC has been supporting the Tegucigalpa Teaching Hospital (TTH), the main public referral hospital for the Central District -Tegucigalpa and Comayaguela cities and surrounding communities-, through a project with the objective to provide quality emergency care to the wounded and sick arriving to the Emergency Services (adult section) of the TTH. The project focusses on timely and proper triage classification at entry of the emergency services, adequate and timely referral to the appropriate services within the emergency department, improving quality of care by unifying the internal and surgery emergency services (promotion of emergency medicine) and the implementation of services meeting international standards of healthcare. Moreover, the project has increasingly focused on the provision of quality care prehospital emergency services connected to the emergency services provided at hospital/TTH level, promoting the concept of continuum of care. Following this continuum of care concept, a prehospital capacity building strategy, in collaboration with the National Society, has been put in place with the objective of increasing the skills of the prehospital providers through (internationally certified) trainings such as the NAEMT-PHTLS training.
The following graph visualizes the concept of the Honduras Hospital project with the main activities in the prehospital arrow (targeted trainings for ambulance providers), the triage and the ER arrow.
Priorities set for 2021:
• Consolidation of the triage system implemented by the ICRC in TTH
• Support for the creation of the TTH´s Integrated Emergency System (unification)
• Elaboration and implementation of a Mass Casualty Plan for TTH.
• Integration of emergency medicine topics into UNAH´s Faculty of medical sciences academic curricula.
• Focus on capacity building activities to improve hospital and prehospital emergency care services.
• Strengthening of the prehospital emergency care system by providing technical support on coordination of services (including a communication system between prehospital and hospital services), provision of trainings and elaboration of guidelines/protocols (e.g. MCP)
• Reinforce the referral/counter referral system with the peripherical prehospital clinics.
2. Rational
According to internal HON ICRC data, in 2020 the TTH Emergency Department (ED) received approximately 52,000 patients of which 25% were brought in by ambulances of different prehospital emergency services providers, without any previous communication with the Hospital. Of these 25%, approximately 8 % were classified as red (very urgent) and 11 % as green (nonurgent), according to the TTHs Triage protocol elaborated by the ICRC in 2019 based on international standards.
This demonstrates that the prehospital and hospital emergency services are not functioning in coordination and that there is a need to reinforce and align triage criteria between hospital and prehospital emergency services as well as improving the referral/counter referral system to other health services according to the severity of the patient’s condition and the availability of services and resources.
In SAL despite the drop in homicides, numbers of SV (2,894), forced displacement (454,000) and missing persons, have significantly increased. Trauma from weapon-wounds and assault related trauma continues being the leading cause of death for young adults in SAL, many of which occur while the victims await transfer to a more specialized facility. Still there is no standardized training program to ensure comprehensive treatment for injured patients during this interim. According to the MoH, the number of armed violence victims reached a number of 30,000 new cases in the past 5 years, greatly impacting hospital emergency care and the healthcare economy in places like Zacamil National Hospital (ZNH), which is where ICRC implemented its Emergency Department (ED) project to upgrade quality of attention, not only for trauma patients but for all VoV. There is a need to increase quality basic emergency care, standardized protocols for trauma patients and an increased focus on quality care at an institutional level.
3. Focus of the review
General objective
Analysis of the current access and functioning of the prehospital emergency services system and the identification of gaps as well as possible ICRC support activities to address identified needs for the wounded and sick (direct or through the national society and other actors), with a focus on Tegucigalpa and San Salvador, and its direct surroundings.
Specific objectives:
Understand and document how the Honduran National Prehospital Emergency Care System and El Salvador Medical Emergency System are structured and its functioning, including:**
Mapping of national and international actors involved in the provision of services**
Mapping of public health care services in and around Tegucigalpa (CLIPERS, health centers, referral system) and San Salvador district (Hospital referral system, and the focus area to be discussed with the mission)**
Identification of government dependencies and coordination with/by authorities (SeSal, SINAGER, COPECO, MINSAL – SEM, FOSALUD, Comandos de Sanidad Militar, Instituto de Seguridad Social, etc.)**
Analyze the intra institutional coordination between actors involved, including the hospital referral emergency services**
Identification of the main difficulties and challenges that hamper proper functioning of the system, including coordination with hospital emergency services
Obtain and analyze statistical data on prehospital emergency attention and transport of patients from the different institutions with focus on trauma and violence cases (including sexual violence) and referrals to the TTH, Hospital Nacional Zacamil, Hospital Rosales.
Identify coverage of geographical areas by prehospital emergency actors/institutions
Identify accessibility constrains for emergency patients (wounded and sick in relation with violence) in need of pre-hospital emergency care (safe, effective treatment, or are referred to the health structure referral system)
Identify accessibility constraints for prehospital emergency institutions in Tegucigalpa and surrounding communities (in relation with violence and violence against PHEC services: ambulances, PHEC providers and patients).**
Analysis of the triage and patient care protocols used by the prehospital care providers
Understand the activation of the National Disaster Risk Management System (SINAGER) and its coordination during disaster crisis by government.
Assess Pre-hospital Emergency Care quality services (safe, confident, well-skilled and equipped Pre-hospital Emergency Care providers), prior to their referral if needed
Mapping of the current existing educational options (available trainings and curricula) in prehospital emergency care. CRH - Unitec / UNAH – COPECO / Catholic University. SEM, FOSALUD and SRC.
What are the needs in terms of resources (material, equipment, personnel, training, etc) to guarantee a properly function system**
Analysis of the impact of the COVID-19 on the functioning of the prehospital emergency services system.**
What is the general perception ( as well as understanding and acceptation ) of the local community on the work of a paramedic/EMT and an ambulance services. **
CAMERA tool related objectives
- Analyze the feasibility of the implementation of the CAMERA tool in Tegucigalpa; need for resources (internal and external), coordination with authorities, academics and actors involved in mass casualty planning (health authorities, prehospital emergency actors, security authorities, etc.)
- Analyze the currently existing protocols regarding mass casualty management
- Analyze currently available resources to manage mass casualty incidents in Tegucigalpa
4. Authority and Responsibility
The review is under the responsibility of the ICRC Health department (Mission, Delegation and Geneva). Support from the GVA prehospital expert is expected to closely collaborate with Health and Management colleagues to provide feedback and support in the elaboration of recommendations for future activities. **
5. Audience
Internal: ICRC Regional Delegation Health Coordination and Management (both at mission and Delegation level), GVA Health department
External: Norwegian Red Cross, HON and SAL National Society.
6. Methodology
Timeline: the review will need to be completed in the 3rd quarter of 2021, with a field visit of at least 8 weeks to enable direct interviews and observations on functioning and coordination of prehospital emergency services and the connection with the ICRC Hospital project.
Concerns/input from all involved parties should be taken into consideration in the development of the assessment report. Information is to be gathered from (health) authorities, relevant (health) actors, prehospital care providers, communities, other donors. **
Internal **
1. Interviews with ICRC staff in mission/region which are related to the project.**
2. Desk review – relevant documents and statistics available in Team Space (project documents, MoU, QHTR, MFR, EOM reports) and the institutional databases (MAD Hospital and Prehospital, PROT6) and statistical analysis specific to the hospital project.**
External **
1. Interview with National Societies (HRC and SRC)**
2. Interview with local MOH key stakeholders **
3. Interview with Prehospital and Emergency Authorities and actors (COPECO, CV, 911, Bomberos, Police, SEM, FOSALUD, Instituto del Seguro Social and Comando de Sanidad Militar, etc)**
4. Accompany prehospital emergency providers **
5. Interview and accompanying TTH Emergency department staff **
6. Interview with other health actors involved in trauma/ED/Pre-hospital care.**
7. Consultations/patient questionnaires with beneficiaries**
8. Interview with academic sector**
7. Human Resources (12 weeks)
· Experienced Prehospital Emergency Care specialist; prehospital/paramedic, doctor or nurse with experience in both prehospital emergency care and hospital emergency care; full understanding of the continuum of care concept.
· Experience in emergency triage implementation at prehospital and hospital level.
· Experience in management of mass casualty incident management
· Native or fluent Spanish is a must
8. Deliverables
· Report on findings and recommendations in line with the objectives set in this document.
· Presentation of main findings and recommendations to ICRC (mission) management and coordination**
· External communications report on findings and recommendations adjusted to the external actors addressed.**
How to apply:
Please send CV and motiivation letter to rcoronaguzman@icrc.org with Subject "Consultor/a para evaluación de servicios prehospitalarios HON/SAL"