Setting
We conducted a prospective cohort study at two hospitals in Sierra Leone, a West African country of over 7.5 million people [13]. Ranked 182nd of 189 countries by the Human Development Index [14] and with a life expectancy that is only 54.7 years [14], Sierra Leone is among the least developed countries worldwide. The 2014–2016 Ebola virus disease epidemic devastated an already fragile health system—staff losses and shaken community confidence in health facilities led to further deterioration of health services and outcomes [15]. The trainings were held at two hospitals in Sierra Leone–Koidu Government Hospital (KGH) and Connaught Hospital. KGH is a public secondary hospital with 170 beds located in Kono, a rural district in eastern Sierra Leone, with a catchment population of 506,100 as of the most recent 2015 census [13]. Connaught Hospital, located in the capital of Freetown, has 300 beds and serves as the national’s main public tertiary hospital. The course content and study design were finalized prior to December 2019, when the first reports of COVID-19 became public.
The Sierra Leone MoHS has emphasized that lack of human resources is “a major contributor to the poor health outcomes seen in Sierra Leone,” and identified “ongoing in-service training and support for all cadres” of healthcare workers as a key priority [16]. A nationwide shortage of doctors in Sierra Leone is exacerbated by their disproportionate concentration in urban areas. For example, Freetown has 1.1 doctors per 10,000 population [17] while Kono District has 0.08 doctors per 10,000 population [17]. In contrast, Community Health Officers—advanced practice providers with 3 years of training—are more evenly distributed across the country and are the principal frontline clinicians in many rural areas [17].
Emergency and critical care services are underdeveloped in Sierra Leone. An assessment of seven hospitals in Freetown found significant deficiencies in emergency and critical care services across multiple domains [18]. Only 67% of facilities had provided training to staff in adult emergency care and 50% had provided training for adult triage [18]. Sierra Leone does not have a formal postgraduate training program in emergency or critical care [18].
Course structure
The BEC course is a five day, in-person training consisting of lectures and hands-on skills stations [8]. The course emphasizes a systematic method for assessment and stabilization of all patients using the ABCDE (airway, breathing, circulation, disability, and exposure) approach [8]. The first day is an introduction to the ABCDE approach with each of the subsequent four days focussed on applying this approach to specific conditions (Fig. 1). Although developed prior to the COVID-19 pandemic, much of the BEC course content has direct relevance to COVID-19. Notably, the third day is devoted to acute presentations of difficulty in breathing. Specific sessions include lectures on assessment, evaluation, and management; interactive case presentations; and hands-on teaching of essential skills such as basic airway manoeuvres, basic airway device insertion, oxygen administration, and bag-valve-mask ventilation. The training courses in Kono and Freetown were conducted sequentially during February 2020 in collaboration with the non-profit organization Partners In Health (PIH). Attendance and successful completion of all course components, demonstrated proficiency in all skill stations, and a score above 75% on the post-course knowledge assessment were required to pass the course. Four facilitators delivered the courses, with a trainer to trainee ratio of 1:3.8 and 1:4.5 for Kono and Freetown, respectively. The facilitators included two physicians from the United States and one clinician and one nurse from Sierra Leone. Facilitators were selected based on leadership ability, prior teaching experience, and emergency and critical care experience. Both facilitators from Sierra Leone had previously taken the BEC course. Content covered over the five days of the courses included all core BEC content.
Participants
Nurses, community health officers, and doctors providing clinical care for critically ill patients in emergency or inpatient settings in Sierra Leone were eligible for invitation to the training. Participants were nominated by staff from PIH and MoHS. Eligibility was not restricted to Connaught Hospital or KGH—participants could come from any public sector hospital in Sierra Leone. All participants were over the age of 18. The Partners Institutional Review Board (Protocol#: 2020P000209) and Sierra Leone’s National Ethics and Scientific Review Committee provided ethical approval.
Data collection
Pre- and immediate post-course assessments of knowledge and confidence are an essential component of the BEC course and were administered to all participants regardless of their participation in the study. On the first day of each training, all participants were approached for written informed consent and only data from those who provided consent were included in the study. Pre-training assessments were administered on the first day of each course and immediate post-training assessments were administered on the final day of each course. Both pre- and immediate post-training assessments were completed using paper forms. To assess knowledge retention and durability of impact, study participants were also asked to complete knowledge and confidence assessments at six months. Recognizing that the COVID-19 pandemic had created an increased demand for emergency and critical care services between initial study design and the pre-planned six month assessment, we developed a questionnaire with ten items related to COVID-19 and amended the study protocol to administer the COVID-19 questionnaire, in addition to the pre-planned knowledge and confidence assessments, at six months.
Data were managed using REDCap electronic data capture tools [19]. Results from completed paper versions of the pre- and immediate post-course knowledge and confidence assessments were manually entered into the REDCap database. The six month follow-up was conducted by sending participants links to online versions of the knowledge, confidence, and COVID-19 assessments via email and SMS/WhatsApp messages using the survey function in REDCap. Two weeks later, participants yet to complete the six month assessments were sent reminders via phone call and SMS/WhatsApp.
Instruments
We assessed participant knowledge pre-course, immediately post-course, and at six months using a multiple-choice assessment containing 25 questions on course content which is a standardized component of the BEC course materials. We reported participant data as the percent of questions answered correctly.
Participant confidence was also assessed pre-course, immediately post-course, and at six months. Using a standardized instrument, participants rated their confidence performing 34 course skills divided into the domains of 1) overall confidence and skills and 2) specific skills. For each skill, participants rated their confidence on a Likert-scale of 1 (“not comfortable”) to 7 (“very comfortable”). For each skill, we reported the number and proportion of participants responding “very comfortable”. This outcome was selected for consistency with prior studies [10, 12, 20]. For the COVID-19 assessment, a group of content experts developed and refined ten questions on experience and comfort treating COVID-19. These questions were completed as part of the six month assessment. Four were “yes/no” questions, two asked participants to rate their agreement with statements on a Likert scale of 1 (“strongly disagree”) to 7 (“strongly agree”), and the remaining four asked participants to rate specific COVID-19 skills on a Likert-scale of 1 (“not comfortable”) to 7 (“very comfortable”). We report the number and proportion of participants responding “yes”, "strongly agree", or “very comfortable”.
Statistical analysis
Data were analysed in Stata (Release 16). All participants that completed the course (i.e., attended all five days and completed immediate post-course knowledge and confidence assessments) were included in analyses. A passing score on the post-course knowledge assessment was defined as greater than 75% (at least 19 out of 25 questions) correct. Categorical variables were described using frequencies and proportions. Given the differences in training sites (urban tertiary vs. rural secondary) we also broke down outcome reporting by training site. Continuous variables were summarized by means, 95% confidence intervals, medians, and interquartile ranges. We compared mean test scores using paired Student’s t-tests and proportions of participants “very comfortable” with course skills using McNemar’s exact chi-squared tests for paired data. We used Wilcoxon matched-pairs signed-rank test for comparing the median number of skills participants rated “very comfortable”.
In additional analyses we compared mean knowledge scores by follow-up status using a two sided Student’s t-test. We also compared median number of skills participants rated “very comfortable” by follow-up status using Wilcoxon rank-sum test.