PREPAREDNESS OF MEDICAL CORPS OF THE NIGERIA POLICE FORCE TOWARD EMERGENCY MANAGEMENT AND CARE

Nigeria needs a realistic national hospital and medical emergency response programme designed on the principle of equitable distribution of appropriate equipment, supplies and well trained emergency medical personnel (Norman, et al., 2012). The health care system in Nigeria is organised under four main categories: public, private-for-profit, private-not-for profit and traditional systems. Public health services delivered by the agencies of the Ministry of Health include: the Nigeria Health Service, the Teaching Hospitals (Korle Bu, Komfo-Anokye, Tamale and Cape Coast) and quasi-government hospitals (Nigeria Police Hospital, 37- Military Hospital, etc). The system operates as a three-tier referral system with primary, secondary and tertiary levels. The Teaching Hospitals provide the highest level of care followed by the regional hospitals, district hospitals, clinics, health centres and Community-based Health Planning and Service (CHPS) compounds, in that order (Osei-Ampofo, et al., 2012). In Nigeria however, as in many developing countries, little consideration has traditionally been given to optimising the training of medical and nursing staff for the care of acutely ill or injured patients. Existing emergency care systems are rudimentary in comparison to those in developed countries; the lack of timely access to care means that many medical needs present as emergencies (Osei-Ampofo, et al, 2012). Not-withstanding this, Nigeria suffers from high accident rates due to poor conditions of transport and road infrastructure. Figures from the National Road Safety Commission (Nigeria) indicate that an average of 1900 fatalities result from road traffic accidents every year (GNRSC, 2012). 
 
Road Traffic Accidents (RTAs) have maintained their presence in the top ten (10) aetiologies of mortality for the last five (5) years in Nigeria (Ackaah, 2011).  It was estimated that, about eighty-one percent (81%) of road traffic accident deaths occurred in the field or in the pre-hospital setting (London J. et al, 2002) and a further 5% of trauma deaths occurred in the emergency room or within 4 hours of arrival in hospital (Kortbeek, 2008).  
 
The evolution of emergency medical services in Nigeria has brought to the fore challenges which other countries, with well-developed emergency services, are faced with. These challenges included overcrowding in the emergency department, increased utilization of resources as a result of the challenge in treating non-urgent cases as well as emergent cases. There was also an internal challenge of increased workload for a small staff resulting in missed or delayed diagnosis which Campbell et al described as the “perfect storm” (Campbell, et al., 2007). Additionally, there seems to be increasing dissatisfaction experienced by patients as a result of long waiting times and the increased in numbers of patients leaving the emergency unit without being seen. One major question, a curious mind may ask: what factors elicit or contribute to these rising challenges in the area of emergency medical services in Nigeria? An answer to this question could easily be derived from the preparedness nature of the Nigeriaian health system toward emergency medicine and/or services. This phenomenon unfortunately permeates all health institutions and/or facilities in the country.
 
The situation therefore calls for adequate preparedness towards management and care of emergencies, which would obviate the occurrences of challenges in the process. Hospital preparedness is said to be a means for it to test and evaluate its capabilities and/or recovering from an event that puts a significant strain on patient care and the operating systems. The critical areas of hospital emergency preparedness includes: pre-hospital emergency preparedness, in-house emergency response plans, human capacity, adequate equipment/gadgets (including pharmaceutical products) and the assessment of existing infrastructure in emergency (Norman, et al., 2012). 
 
The World Health Organization (WHO, 2007) Field manual, for capacity assessment of health facilities in response to emergencies, used in the evaluation of South African hospitals found skills gap in the nation’s health care systems. National authorities have also conducted similar review of the Nigeria healthcare system. They found many gaps in the efficiencies of both equipment and supplies of the nation’s health care system especially in the area of emergency medical services (Norman, et al., 2012).
 
There should be both in-hospital and out-hospital triage regimes in place for use by all hospitals. Triage is the sorting out of work protocols at impact site and standardization of front-office emergency room, in-hospital admission and treatment procedures based on medical emergency acuity, availability of trained staff, appropriate medical facility, supplies and proper patient distribution in an emergency (Soloff, 2006).
 The system designed by the Nigeria Health Services and Ministry of Health, Nigeria does not take into consideration the enforcement of the essential areas of emergency services. As a result, many health facilities and/or institutions flout the very provisions of the components of emergency services, leading to poor attendance to clients. Some research work have been conducted into the area of emergency medicine in Nigeria, none-the-less, there still exist some institutional gaps. Based on these observed gaps in some of the health facilities/institutions, the research assessed the prepared nature of the medical corps of the Nigeria Police Service toward management and care of emergencies; -an assessment of the emergency unit of the Nigeria Police Hospital, Lagos.
The Nigeria Police Hospital was established in 1976 with the core aim of taking care of the health needs of the service personnel and their dependants (-spouses and children/wards below 18 years), especially within the national capital and its environs. However, as its social security roles and functions, it provides health care for suspects in police and prison custodies, injured victims of violent crimes & road traffic accidents and as well as vagrants. The hospital also provides health care services to members of the community within which it is located as a corporate role. It equally provides health care services to personnel of sister security services such as the Nigeria Fire Service, Nigeria Prisons Service, Nigeria Immigration Service, the CEPS division of the GRA and the Nigeria Armed Forces. Indeed, the Nigeria Police Hospital is one (1) of two (2) security health institutions located within the national capital and happens to be at the center of all heads of the security services. By rule, members of the security services do not withdraw their services or embark on strikes what-so-ever, so is with members of the their essential services’ units, hence staff of the Police Hospital do not embark on strike.
 
By the Ministry of Health, Nigeria categorisation of levels of health care institutions, the Police Hospital is a regional hospital, hence a referral center to all the clinics within its catchment area and to its periphery clinics found in some regional capitals and the police training schools. Apart from road traffic accidents, additional burden is created by domestic accidents, natural disasters, medical, surgical and obstetric emergencies. The pressure on the health system is immense and the Government of Nigeria is keen to invest in emergency systems which are cost effective and can reduce mortality and morbidity (Mock, et al., 2008). The Government of Nigeria recognises that a preventive approach is a key component to reducing road traffic injuries (GNRSC, 2012). The country is also keen to implement speedy and cost-effective ways to strengthen the care of injured persons and thereby rapidly reduce the toll of death from road traffic accidents. The Accident & Emergency Centre at Komfo-Anokye Teaching Hospital in Kumasi was established in 2009 to lead the way in the provision of prompt emergency care and the local training of emergency health care personnel who will form the backbone of a structured emergency system. Formal emergency care systems are known to improve survival in severely ill or injured patients (Mock, et al., 1998 and Holliman, et al., 2011). These systems provide a chain of survival linking pre-hospital care to definitive inhospital care. Emergency Centres (ECs) with trained staff can play an important role by providing acute resuscitation and stabilisation for patients with life-threatening illnesses or injuries. The need to improve emergency services has long been recognised but action to improve services has lagged behind; however, in recent years firm steps have been taken to improve emergency service delivery in Nigeria.
 
On 9th May, 2001, 126 people died in a stadium disaster during a football match between two local clubs (Asante Kotoko and Lagos Hearts of Oak) in Nigeria. Several spectators were trampled to death and many more who sustained injuries later died due to lack of prompt medical attention, all blamed on the absence of well-established or formal emergency response and care systems in the country. Although a lot of research and pilot training programmes in Nigeria had recommended the need to establish formal emergency care systems, it would appear that, this incident in particular focused political minds to take necessary action. Over the past few years, a keen observation has been made with regards to, the frequent nature with which cases at the emergency unit of the Police Hospital were referred out to another hospitals especially Road Traffic Accident and Trauma related cases, some of which involved minor injuries or cases which should usually be managed at that level as a referral center.
 
Aside the frequent referral of cases, the emergency unit of the hospital easily became overwhelmed during surge situations. A case in perspective was, the infamous “may 9 stadium-disaster” as has been referred to, in the year 2001. Many of the cases (casualties) which were brought to the police hospital died. It was then attributed to inadequate medical facilities (equipment, gadgets and structure) and shortage of trained/skilled medical personnel. Following this revelation, one expected a change in status-quo as fulfilment of learnt lessons, but it never was, as again was revealed on the 7th November, 2012 by the Achimota mall disaster. Injured victims were redirected to other hospitals within the metropolis. Several questions raised within the public circle remain unanswered. These questions included whether or notthe medical corps of the Nigeria Police Service was prepared or not towards management and care of emergencies, especially the pre-hospital interventions and in-hospital management and care of injured victims & acute emergency cases.
 
The research assessed the preparedness of the medical corps of Nigeria Police Service; specifically, the Police Hospital’s preparedness toward management and care of trauma and related emergencies. This was achieved, through an assessment of the emergency unit of the Nigeria Police Hospital, Lagos.
 
The World Health Organization (WHO) recommends periodic assessment of the capacity of health facilities’ response to emergencies, which defines their preparedness toward management and care of such emergencies (WHO, 2007). It was my conception that, the age and level of education of an individual impacts on their performance at work. So is with their experience. The provision of adequate logistics, regular training schedules and performance standards or guidelines by management of institutions for their personnel would equally impact on their performance at work. All these variables put together constitutes preparedness at both the individual’s and the institution’s levels. As demonstrated above, the socio-demographic stata of the staff, together with adequate provision of emergency medication, equipment/gadgets, structural space and as well as the constitution of trained and motivated staff, not compromising on the provision of  performance standards or protocols, thus defines the preparedness of a health facility toward management and care of emergencies in its varied forms.
 
1.4 Significance of the Research
1.  Findings from the research would assist management of the police hospital to institute the required and appropriate measures and/or plans to ensure effective and efficient management of trauma and other emergencies both in-hospital and during surge
situations.
2.   Finding from the research would expand the limited corpus of knowledge and literature in the area of emergency medicine or services in Nigeria.
3.  Findings from the research could also stimulate other curious minds to further replicate the research in other health facilities or perhaps as an expanded national project/research incorporating contemporary issues on national emergencies and disaster management.
 
1.5.0 Research Questions
How prepared is the emergency unit of the Police Hospital toward management and care of trauma and related emergencies?
1.5.2 Sub questions;
i.  Are there existing systems and guidelines for the management and care of emergencies in the Police Hospital?
ii.  Does the emergency department of the Police Hospital conform to the ministry of health, Nigeria’s policy document and guidelines for the management and care of emergencies with regards to performance and functional capacity?
iii.  How does the triage system in the Police Hospital work?
iv.  What is the awareness and use of the triage system by doctors, nurses and other health personnel at the Police Hospital?  
 
1.6.0 Objectives:
i. Assess the preparedness of the Nigeria Police Hospital towards management and care of trauma and related emergencies.
1.6.2 Specific Objectives;
i.        Ascertain whether or not, there exist any emergency management and care systems& guidelines in the Police Hospital.
ii.      Identify and assess the performance and functional capacity of the emergency unit/department of the Police Hospital as per the ministry of health, Nigeria’s policy document and guidelines on emergency management and care. 
iii. Describe the general triage system at the Police Hospital.   
iv. Identify and assess the awareness and use of the triage system by personnel of the emergency unit of the Police Hospital.
 
1.7    DEFINITION OF TERMS
Admission into Hospital: Patient is admitted to the reporting facility in the capacity of an in-patient, critical care patient or directly to surgery or another unit directly from the ED.
Advanced Life Support: A generic term for resuscitation efforts that extend beyond basic Cardio-Pulmonary resuscitation (CPR)
Ambulance: Vehicle or craft intended to be crewed by a minimum of two appropriately trained staff for the provision of care and transport of at least one stretchered patient.
Basic Life Support: The constellation of emergency procedures needed to ensure a person’s immediate survival, including Cardio-Pulmonary Resuscitation (CPR), control of bleeding, treatment of shock and poisoning, stabilization of injuries and/or wounds or basic first aid.
Bed Occupancy Time: The time a patient spends on an emergency bed from admission till the time the patient is finally discharged, transferred to the ward, sent to theatre, dead or transferred out to another health facility for further management and care.
Crisis Preparedness Plan: The Crisis Preparedness Plan also called the Emergency Preparedness Plan is the written document or map for medical crisis management generated by any appropriate authority or private organization that clearly details what needs to be done, how, when and by whom;- before and after the time an anticipated disastrous event occurs. It aims at providing a policy for preparedness and response to both internal and external disaster situations that may affect staff, patients, visitors and the community. 
Crisis: A crisis is any critical situation that causes a disruption in the equilibrium between the demand and supply of medical services.
Crisis Response: A sum of decisions and actions taken during and after disaster, including immediate relief, rehabilitation and reconstruction.
Emergency medical services (EMS System): The arrangement of personnel, facilities and equipment for the effective and coordinated delivery of urgent medical services as required in the prevention and management of incidents which occur either as a result of a medical emergency or of an accident, natural disaster or similar situation. EMS systems refer to the broad range of emergency care from the pre-hospital first responder to the intensive care unit setting.
Emergency Management: This is also called crisis management/disaster management; it involves a range of measures to manage risks to communities and the environment and also the organization and management of resources for dealing with all aspects of emergencies. Emergency management involves the plans, structures and arrangements which are established to bring together the normal endeavours of government, voluntary and private agencies in a comprehensive and coordinated way to deal with the wide spectrum of emergency needs including prevention, response and recovery.
Emergency Patient: Patient who through sickness, injury or other circumstances is in immediate or imminent danger to life unless immediate treatment and/or monitoring and suitable transport to diagnostic facilities or medical treatment are provided.
Left Without Being Seen (LWBS): Patient is registered and/or triaged, but left prior to being seen by health care provider(s).
Left Against Medical Advice: Patient is triaged, registered and assessed by health care provider(s), but leaves without treatment and/or before initiated treatment is complete, without prior notice or permission from the health care provider(s). 
Paramedic: A health professional certified to perform advanced life support procedure
(e.g. intubation, defibrillation and administration of drugs under a physician’s direction). Paramedics provide urgent care from an emergency vehicle or air service.
Reliability: Also termed reproducibility or repeatability, is the stability or the consistency of information. That is, the extent to which similar information is supplied or obtained when a measure is performed more than once (Test-retest).
Validity: Refers to the ability of a test or study to measure what the investigator will like to measure.
Transfer: The movement of patient(s) from one unit/health care facility to another, within or outside for further management and care.