An assessment of emergency care capacity at three hospitals in the Harare metropol, Zimbabwe: A descriptive cross-sectional study using the WHO Hospital Emergency Assessment Tool (HEAT)

Abstract

Introduction

Zimbabwe has experienced significant population growth, as well as a rise in noncommunicable diseases, impacting the demand for emergency care services. However, there is limited data on the state of Zimbabwe's emergency care systems to meet this growing need. This pilot study aimed to assess the capacity of Emergency Departments at three major referral hospitals in Harare, Zimbabwe.

Methodology

A cross-sectional descriptive study was conducted using the World Health Organization’s Hospital Emergency Assessment Tool (HEAT). Key participants from each hospital were interviewed in 2023 to gather data on facility characteristics, human resources, diagnostic services, and signal functions.

Results

Three large hospitals offering round-the-clock emergency care services were included. A core of dedicated doctors and nurses manned the Emergency Department in all three facilities, yet none had specific training in emergency medicine. There were various significant challenges to the operation of emergency departments, including access to water for one, and two with limited capacity to perform emergency diagnostic tests as they lacked the necessary equipment and consumables. One hospital reported a sufficient set of emergency protocols and guidelines, while the other two hospitals exhibited varying levels of availability in these areas. Two facilities reported adequate capacity in performing >85 % of signal functions. Common challenges included the absence of emergency-trained staff, lack of a formal triage system, and equipment deficiencies, all of which constrained their ability to deliver certain signal functions.

Conclusion

This assessment revealed a spectrum of service availabilities across the three hospitals, with common barriers identified. To strengthen the country's emergency care system, efforts should be focused on improving consumable supplies, prioritising training initiatives in emergency medicine to build a skilled workforce and implementing standardised protocols and triage systems across facilities. Continuous monitoring and evaluation of implemented interventions are necessary to ensure sustainable improvements in emergency care delivery.

African relevance

• •The World Health Organization has produced several tools for evaluation of emergency care capacity of health systems, including the Hospital Emergency Unit Assessment Tool (HEAT)
• •A comprehensive assessment can highlight the needs and priorities of emergency care systems dvelopment.
• •Assessing emergency units can help emergency care systems evaluate their preparedness to respond to natural disasters, disease outbreaks, and humanitarian crises in Africa.
• •Efficient and well-equipped emergency units resulting from such assessments can potentially reduce morbidity and mortality rates associated with emergencies.
• •Emergency care would seem to have been somewhat neglected in Zimbabwe, and this article demonstrates some of the gaps and explores the difference between public and private facilities in the capital, Harare, which is not unlike the situation in many African countries.

Introduction

Like many low and middle-income countries (LMIC) in sub-Saharan Africa, Zimbabwe is dealing with a surge in demand for emergency care services amid poorly developed and persistently challenging access to Emergency Care Systems (ECS) [1]. The COVID-19 pandemic has revealed the weakness of LMIC ECSs in coping with the escalating burdens of both non-communicable and infectious diseases [2]. Compounded by the economic downturn of the last decades, Zimbabwe's healthcare system is in a protracted crisis [3]. It is characterised by a scarcity of skilled healthcare professionals, with only 1.3 doctors and 28 nurses per 10,000 people [4]. The lack of formal training in Emergency Medicine (EM) for doctors further compromises the prioritisation and delivery of high-quality Emergency Care (EC) [5]. Emergency Medicine as a speciality remains unrecognised, with no EM training programs in Zimbabwe.

Recognising the urgent need to strengthen ECS, the World Health Organisation (WHO) advocates for establishing well-organised systems integrating simple, cost-effective emergency interventions, particularly in LMIC. Evidence suggests that these interventions have the potential to prevent up to 50 % of avoidable deaths and disabilities [2]. One such intervention is the comprehensive assessment of current ECS functionality, using the WHO standardised toolkit - the Hospital Emergency Unit Assessment Tool (HEAT) to objectively evaluate emergency care capacity, encompassing hospital infrastructure, human resources, clinical service availability, and signal functions [6]. Signal functions assess an Emergency Department's (ED) ability to perform critical, time-sensitive interventions essential for managing life-threatening emergencies. The absence of critical interventions or services signifies a limited capacity to deliver emergency care [7,8].

Prior research details HEAT assessments in other LMIC settings, including Zambia, Tanzania, Nepal, Eswatini and Ethiopia [[8], [9], [10]]. This study assessed the EC capacity at Harare’s three largest hospital EDs, characterising EC resources, pinpointing service delivery gaps and underlying causes of system failures, to enable policymakers and hospital managers to develop targeted interventions for a broader ECS improvement strategy for these hospitals and the Harare Metropolitan ECS.

Methodology

This cross-sectional descriptive study utilised the HEAT toolkit and process to evaluate the facility-based emergency care delivery capacity of three major referral hospitals in Harare, the capital of Zimbabwe, between September 1 and October 31, 2023.

According to the 2020 census, the Harare metropolitan district has an estimated population of around 3 million [11]. The district is marked by significant inequality, with 60 % of its residents living below the poverty line [12]. This economic context influences healthcare choices, with many relying on public healthcare due to its affordability and availability. Three large hospitals were approached to be included in the study as a starting point and were selected to give a picture of the biggest hospitals in the city. Two major public teaching hospitals, Parirenyatwa Group of Hospitals and Harare Central Hospital were deliberately included due to their significant role in providing most of the emergency care services in Harare’s public sector. They offer specialised tertiary services and receive most referrals for critically ill patients nationwide [13]. Avenues Clinic is Harare's largest private referral hospital, catering to many privately insured emergency medical cases. For each hospital, approval was obtained from management, who then assisted in identifying key participants who were administrators and clinical staff (doctors, nurses, radiologists, lab technicians) who had worked directly with the ED for more than three months. Participants were contacted, and if agreeable, interviewed in person at their institution while being shown the HEAT tool. Following the HEAT tool guidelines (Addendum 1 (supplementary material)) after obtaining written consent, the data collection process involved face-to-face interviews with individual participants and walkthrough sessions, during which the primary researcher made observations in each ED. Proficient in the HEAT tool, the primary researcher collected data and filled in the tool. Key informants contributed to specific sections of the HEAT according to their areas of expertise. Objective data collection sections, such as those detailing ED human resources, were completed with only necessary key participants, while interviews in subjective data sections were conducted with a minimum of three participants per HEAT section to improve result accuracy. The HEAT employs availability rating questions to evaluate service or resource capability on a scale from 1 to 3: 1 indicates generally unavailable, 2 denotes some availability, and 3 signifies adequately available. When a question has three or more divergent responses, the median response becomes the final response. Average rating scores were calculated for each section and hospital to determine summative availability ratings.

Data was entered and analysed in Microsoft Excel, where simple descriptive statistics were generated. Ethical approval was obtained from the Medical Research Council of Zimbabwe (MRCZ/B/2556) and the University of Cape Town Human Research Ethics Committee (HREC: 531/2023). Institutional approvals were obtained, and the hospital administrators reviewed the results and agreed to their publication without influencing the conclusions. Anonymising hospital identities proved challenging in this study, and hospitals have been de-identified where possible, and only aggregated data is presented.

Results

As outlined in Table 1, a total of 25 key informants were interviewed to complete various HEAT elements.

Table 1.

Key participants' designation and HEAT sections completed^ab.

Designation/department	Hospital Ac		Hospital B		Hospital C
	Section answered	No of participants	Section answered	No of participants	Section answered	No of participants
Hospital Administrators	1, 3.1, 3.2	1	–	–	1.1, 1.2, 1.3	1
Health information systems manager	1.1, 1.2, 3	1	1.1, 1.2	1	1.1, 1.2	1
ED Matron/nursesd	1.2, 1.3,1.4, 2, 3, and 4	1	1.2, 1.3, 1.4, 2, 3 and 4	2	1.3, 2, 3.1	1
ED Doctorsd	1.2, 1.3, 1.4, 2, 3, 4	3	1.3, 1.4,2, 3, 4	3	1.3, 1.4, 2, 3,4	4
Radiology technician	1.4,	1	1.4	1	1.4	1
Laboratory technicians	1.4,	1	1.4	1	1.4	1
Totals		7		9		9

^aParticipants completed sections of the HEAT depending on their areas of expertise.

^bDetailed HEAT sections include 1. Facility Characteristics (1.1 Identifying Information, 1.2 Facility Metrics, 1.3 Infrastructure and essential equipment, 1.4 Diagnostic Services); 2. Human Resources (2.1 Emergency Care Clinical Providers, 2.2 Consulting services Available to the Emergency Unit); 3. Clinical Services (3.1 Access, 3.2 Triage, 3.3 Guidelines, protocols and checklists, 3.4 Ancillary Services, 3.5 Quality improvement); 4. Signal functions (4.1 Vital Signs, 4.2 Airway Interventions, 4.3 Breathing Interventions, 4.4 Cardiac Interventions, 4.5 Neurologic Interventions, 4.6 Sepsis Interventions, 4.7 Trauma Interventions 4.8 Obstetric Interventions); 5. Essential Resources for Emergency Care.

^cHospitals were deidentified for confidentiality and to protect reputation.

^dED doctors, matron and nurses were those permanently rostered in the ED.

ED - Emergency Department.

Facility characteristics

All three hospitals offered dedicated 24/7 EDs, separate from Outpatient Department (OPD). All EDs were accessible to ambulances, but one hospital faced challenges entering the resuscitation room due to turns and confined corridors hindering stretchers and wheelchair manoeuvrability. All EDs were staffed by dedicated emergency providers physically present, complemented by various in-hospital specialists available on-call for after-hours emergencies. All EDs offered 24-hour laboratory, radiology, and theatre services.

Hospitals A and B demonstrated significantly greater inpatient bed capacity than C, but C had more ICU beds (Table 2). Admission rates were high for all three EDs.

Table 2.

Annual facility metrics at three Emergency Departments for the year 2022.

Descriptor	Hospital A	Hospital B	Hospital C
ED visits	52 964	44 636	6 530
OPD visits	111 057	110 364	8 400
Inpatient admissions from ED	38 227	39 567	3 000
Total beds in ED	7	10	5
Inpatient hospital beds	1072	1215	134
Functioning operating theatres (24/7)	2	2	1
Functioning ICU beds	5	5	8
Emergency surgical operations	421	298	280
Non-rotating ED Doctorsa	25	20	8
Non-rotating ED Nurses	92	66	11
ED admission rateb	72.17 %	88.64 %	45.94 %

ED – Emergency Department; OPD – Outpatient Department; ICU – Intensive Care Unit.

^anon-rotating – permanently stationed or dedicated.

^bED admission rate = (inpatient admission form ED/ED visits) x100.

Infrastructure and essential equipment availability

Hospital C exhibited adequate infrastructure and essential equipment availability, while Hospitals A and B showed some availability (Table 3). All EDs had grid power and backup diesel generators, and one had additional renewable energy backup. One hospital reported challenges in accessing clean running water, and lacked a dedicated staff room, accessible staff and patient toilet facilities, and consistent handwashing facilities. None of the EDs had dedicated isolation units. Two EDs reported electronic monitoring for <40 % of their beds due to nonfunctioning equipment and financial constraints.

Table 3.

Summary availability rating for services and signal functions in the three Emergency Departments.

Service/ Function	Hospital A		Hospital B		Hospital C
	Average a	% b	Average	%	Average	%
Infrastructure and essential equipment	2.48	61.90	2.10	33.33	2.76	85.71
Diagnostic services	2.35	56.52	2.13	43.48	2.91	91.30
Ancillary servicesc	2.33	33.33	2.67	66.67	2.67	66.67
Consulting servicesd	3	100	3	100	3	100

^aThe average score of all descriptors a hospital archived in each function.

^bThe percentage of functions with reported adequate availability.

^cAncillary services encompass social work, patient transport services within the ED, and security measures.

^dConsulting services refer to specialists who can be consulted to provide expertise in managing specific emergencies or complex cases in the ED.

Diagnostic services

One ED reported adequate point-of-care and lab-based diagnostic capabilities, while the other two hospitals could not provide crucial tests such as troponin and lipase. Two hospitals lacked access to portable X-ray machines, necessitating patient transfer to the radiology department, complicated by the occasional unavailability of radiographers. Hospital C was the sole facility with in-house access to CT scans and reporting by radiologists. One hospital reported a malfunctioning CT scan machine, while the other had no CT. In all EDs, diagnostic tests incurred costs, with one hospital requiring upfront payment while others billed patients later.

Human resources

Despite consistent teams of non-rotating doctors and nurses in the ED, there were no specialised EM providers. While teaching hospitals occasionally had rotating student nurses, none had rotating interns or registrars attached to the ED. Consulting services from the specialties assessed were readily available in all Eds.

Clinical services

All three EDs provided initial life-saving interventions for critically ill or injured patients without requiring payment upfront. However, one hospital would not continue to provide care if patients or their families could not pay for services and would be referred elsewhere. None of the hospitals used a formal triage system or established time targets for patient waiting times. Social worker services were reported inadequate in all hospitals due to lack of funding. One ED demonstrated extensive clinical protocols governing patient management and flow within and beyond the ED, while others had limited availability. Only one ED exhibited a comprehensive approach and protocols for special populations. None of the facilities had syndromic surveillance guidelines for public health coordination.

Signal functions

Signal function availability and critical gaps in emergency care delivery across the three hospitals are summarised in Table 4. Major barriers to performing signal functions were consistently linked to non-functioning equipment, supply stockouts, staff skill and knowledge gaps, and inadequate infrastructure. Although Hospital C had an overall higher capacity for performing signal functions, user fees were a major barrier.

Table 4.

Summary of signal function availability and gaps identified.

Signal Function	Hospital A:	Hospital B:	Hospital C:
Vital signs, airway, and breathing interventions	Avg. Rating a: 1.94	Avg. Rating: 2.00	Avg. Rating: 2.82
-Triaging	Personnel b	✓ c	infrastructure
-Basic manual airway maneuvers	training	training	✓
-Non-invasive ventilation	broken equipment, training	absent equipment	✓
-Invasive airway management	equipment, training	absent equipment	✓
-Asthma, anaphylaxis, tension pneumothorax	✓	✓	✓
-Thoracocentesis	infrastructure, training	training	training

Circulation	Avg. Rating: 2.05	Avg. Rating: 2.10	Avg. Rating: 2.57
-Bleeding control and volume resuscitation	✓	✓	✓
-POCUS performance and interpretation	broken equipment, training	absent equipment, training	✓
-Venous cutdown and central venous line establishment	absent equipment, training, personnel	absent equipment, training	absent equipment, training, user fees
-ECG interpretation,	absent equipment	absent equipment	✓
-Aspirin and thrombolytic therapy	stockout, training	stockout, training	user fees
-ACLS, defibrillation, pacing and cardioversion	absent equipment, training	absent equipment, training	✓
-Pericardiocentesis	absent equipment, training	absent equipment, training	training

Neurologic interventions	Avg. Rating: 2.42	Avg. Rating: 2.74	Avg. Rating: 3.00
-Protection from secondary brain injury, hypoglycemia management, seizure management, mental state exam	✓	✓	✓
-Management of extreme temperatures	absent equipment	✓	✓
-Procedural sedation	training, personnel	✓	✓
-Lumbar puncture	patient factors (declined consent)	patient factors (declined consent)	✓

Sepsis Intervention	Avg. Rating: 2.50	Avg. Rating: 2.74	Avg. Rating: 3.00
Diagnose sepsis, administer antibiotics, and drain abscesses	✓	✓	✓
Iv vasopressor administration	broken equipment, training	stockout, training, absent equipment	✓

Trauma Interventions	2.20	2.70	2.90
-Administer opiate analgesia, initial wound care, closed fracture reduction	✓	✓	✓
-C-spine and fracture immobilization	absent equipment, stockout	stockout	✓
-Three-way dressing for sucking chest wound	stockout	✓	✓
-Antibiotics for open fracture, tetanus and rabies vaccination as appropriate	stockout	✓	✓
-Fasciotomy/escharotomy in ED	infrastructure	infrastructure	infrastructure

Obstetric Intervention	2.67	3.00	3.00
-Assisted vaginal delivery and oxytocin administration	✓	✓	✓
-Neonatal resuscitation	broken equipment	✓	✓

^aThe average score of all descriptors that the hospitals achieved in each signal function.

^breasons for the less-than-adequate rating.

^cSignal function is adequately available, score of 3.

Discussion

This study is the first ED assessment conducted in Zimbabwe using the HEAT. It evaluates the equipment and infrastructural resources within their EDs and assesses their self-reported proficiency in performing critical, time-sensitive interventions for managing life-threatening emergencies. Common challenges emerged across all hospitals, serving as significant barriers to delivering high-quality EC. The study highlights the absence of EM specialists and a formal EM training program in Zimbabwe. EM specialists fulfil multifaceted roles in ECS development and could improve EDs’ EC capabilities and overall patient outcomes.

We found a significant barrier reported across all hospitals was the emergency skills gap among ED practitioners in performing critical lifesaving procedures. These findings echo conclusions drawn from prior assessments in LMICs, where insufficient skills among ED clinicians were identified as a primary factor contributing to inadequate EC provision [[8], [9], [10],14]. In countries where ECS and EM training is not widely established, ED clinicians often lack the necessary skills, leading to inadequacies in performing critical signal functions [15]. EM short courses represent a significant strategy for addressing the emergency skills gap among ED clinicians [[16], [17], [18]]. The WHO has developed an Emergency Care Toolkit (ECT) tailored to LMIC, which includes basic emergency care courses to bridge the skills gap [19]. ECT interventions have been shown to enhance EC delivery, resulting in a notable 50 % reduction in emergency-related mortalities [5].

This study also revealed a shortfall in medical education beyond the lack of EM specialist training, with undergraduate and specialist trainees lacking exposure to ED rotations. Addressing this gap requires EM specialists, and curriculum revision incorporating ED attachments to provide comprehensive exposure to emergency presentations and procedures [20,21].

Public-sector hospitals lacked essential equipment and pharmaceuticals (such as defibrillators). As in many LMIC healthcare systems, insufficient funding compromises the ability of EDs to stock drugs and consumables and procure essential equipment [22]. The consequent absence of equipment and diagnostic services delays and disrupts patient care, leading to ED overcrowding and subsequent complications [23].

We found concerningly high admission rates from the study EDs (46–89 % admission rate in this study) relative to elsewhere (South Africa, 24–31 %) [24,25]. The high admission rates observed across Harare's EDs could indicate a lack of skills and competence in definitive patient management within the ED [26], as well as limited access to healthcare services due to the country's failing health system, and consequently delayed presentation with advanced disease [[26], [27], [28]]. High admissions strain healthcare facilities, impacting staffing, ED resource availability, and bed occupancy.

There was no use of triage tools or prioritisation at reception, a common finding in assessments conducted in LMICs, particularly in regions where ECSs are still in the developmental stages [8]. Lacking a standardised triage system results in inconsistent patient prioritisation, delayed critical interventions, resource wastage, and negative impacts on patient outcomes [29].

Limitations

The study utilised a validated tool and methodology to identify gaps in the emergency care system, presenting an opportunity for quality improvements in facility-based EC delivery. The assessment was confined to just three conveniently selected hospitals in Harare, thereby limiting the validity and generalizability of the findings. A larger and more exhaustive sampling of EDs throughout the country would provide a more accurate assessment of EC capacities. However, we believe the findings are pertinent and likely represent some of the best care in the country. The HEAT tool relies on reported information from key participants which may introduce bias in reporting of system shortcomings, so multiple participants were independently interviewed, and their responses were triangulated to enhance the objectivity and reliability of the findings.

Conclusion

The study revealed differences in EC resources across hospitals, possibly linked to public vs private models. Common challenges identified across all EDs included staffing, equipment, and training limitations. Further case mix studies are needed to understand the diverse range of patient presentations and needs within EDs in Harare for planning and resource allocation. Key areas for improvement include strengthening training through short courses in EM, integrating ED attachments into undergraduate curricula, and establishing local EM residency programs. Prioritising EC equipment purchases or replacement in hospital budgets and fostering public-private partnerships to enhance equipment capacity is vital, as is developing standard protocols for common emergencies.

Dissemination of results

The results of this study were shared with hospital administrators and informally presented to staff during meetings held in the respective Emergency Departments.

CRediT authorship contribution statement

Prince Deka: Conceptualization, Methodology, Validation, Investigation, Formal analysis, Writing – original draft, Writing – review & editing. Peter Hodkinson: Supervision.

Declaration of competing interest

PD is a Zimbabwean doctor who trained at the University of Zimbabwe and did his internship at PGH and HCH. However, he is no longer working in Zimbabwe. PH is an editor of the African Journal of Emergency Medicine but was not involved in any editorial process or review of this submission.